Should we watch out for the giant isomorphic wheel of public health?

When I started working in international alcohol and drug research cooperation, I noticed that the concept of “public health” was sometimes used as a conceptual plough to make questions arable. “We must frame it as a question of public health”, was often stated so as to invest questions with a natural importance. This especially concerned alcohol policy questions. Early on, I realised that in some systems and cultures, especially in the Anglophone world, the concept of public health encompasses an epistemic tool with no exact equivalence in the Nordic countries.

In recent times, as the scientific modus operandi among Nordic scholars has become increasingly international, the Anglophone connotations of certain concepts have found their way into Nordic social science terminology. When a European project wanted to investigate the phenomenon of addiction, this was a natural object of research for countries with strong psychologist, public health and medical research traditions. For others the concept of addiction was in the year 2011 still somewhat alien. In the Nordic countries the epistemic concept of addiction has originally been rather unimportant socially and politically – phenomena of dependency or addiction used to be questions primarily for treatment method research.

Today, the Anglophone uses of the terms addiction and public health have become common in Nordic research and policy. A manifestation of this trend is their appearance in institutional names. The Nordic Welfare Centre, publisher of Nordic Studies on Alcohol and Drugs, coordinates its social science research cooperation on alcohol and drugs under the heading of public health. The public alcohol and drugs research groups and institutions in Sweden, Norway and Finland have all in their own way been incorporated or merged with public health departments or organisations.

The transformation of certain questions into mainstreamed international understandings can be seen as an opportunity for growth and increased relevance for a research field as a whole. It can also be seen as part of a gigantic isomorphic wheel that distances us from our own history and particular welfare political grasp.

What happens, then, when we translate societal phenomena and their conceptualisations from one system to another? Will the large isomorphic wheel mainstream and narrow down the Nordic idea world repertoire available for thinking about alcohol and drug problems? Will it influence our views on the phenomena and, over time, institutionalise them in other simplifications into our public systems? Regarding the ongoing push of alcohol and drug research underneath the public health umbrella in the Nordic countries, it is indeed likely that this is taking place at the expense of some important framings.

In this issue, we have gathered texts that unfold the question of how a public health approach differs from the social sciences and a social seating of alcohol and drug questions. Our aim is to open a discussion that we hope others find welcome and feel encouraged to participate in.

Public health: Origins and conceptual implications

Sophy Bergenheim (2018) starts off the discussion with a general historical account of how public health has appeared as a concept-phenomenon. Discussing the definitions of the collective public, whose health we are referring to with the concept of public health, is to Bergenheim an important gateway for understanding its relative and changing meaning over time. Bergenheim reminds us that, historically speaking, the concepts of “the people” and “the public” have not always involved the masses that are counted and approached on an equal basis. In fact, the control and exclusion of illnesses and genetic deviation were originally performed to serve and protect parts of the populations that were not ill, but able to work and produce. Furthermore, the matters that served to maintain and guarantee a reproduction of the overall workforce capacity were conceptualised under rubrics such as “hygiene”. When accounting for times when the contemporary incarnation of this epistemic project had already become salient in science and policy, Bergenheim mentions the linguistic turn and New Public Health as paradigms that have either synergised, created overlappings between, or strictly demarcated public health and social sciences.

In his comment on Bergenheim’s text Pekka Sulkunen (2018) points out the two-sided nature of the concept of public health. On the one hand, the concept carries an inherent political justification: health is of almost absolute incontestable worth. Its justification draws on the universal consensus that ill-health is something bad. All individuals confront the risk of falling prey to illness and everybody has an interest in minimising this risk and receiving proper treatment if and when problems occur. It translates to a democracy ethos of all people having the right to health and therefore being seen as having the right to be included in health agendas. On the other hand, as Sulkunen points out, the concept inevitably involves an aspect that makes it dependent on causality constructs. Ill-health is understood as caused by something, and the cause must correlate with outcomes of action. The physicality of “illness” – situated in a body – will thus always entail a fixation on positivism, on an epistemic dogma that is perceived as “neutral” evidence.

Alcohol and drugs as questions of public health

In Alex Mold’s piece on how alcohol and drugs use have become framed as public health problems in Britain, the reader is reminded of how recent the public health framing is when it comes to psychoactive substance use (Mold, 2018). For example, the temperance movement did not particularly stress the aspects of health in alcohol problems, and regulation of pub hours is mentioned as an example of an important political question that was not directly connected to the causality to health.

Mold partly ascribes the origin of a public health framing to the medical sphere and to concepts such as alcoholism and addiction. In Mold’s account of more recent developments, the HIV/AIDS epidemic contributed to a conceptualisation of drug use from the perspective of control of health-related issues. In her account of diachronic developments of understandings of issues as matters of public health Mold presents a sequential connection between the focus of medicine and a focus on population health. In her account of the adherent policy approaches, she separates between groups (young people’s substance use) and people (whole-population approaches). Similarly to Bergenheim, Mold sees that a clue for understanding what public health is to be found in answering the question “whose health?”. Mold writes: “Until it is clear whose health is being prioritised, and to what ends, public health will continue to be one amongst many approaches when it comes to dealing with drugs and alcohol” (Mold, 2018, p. 6).

In Kertsin Stenius’ comment on Alex Mold’s text (Stenius, 2018) the Nordic perspective is put into focus. Stenius points out that in comparison with the British context, “public health” is a more problematic concept in the Nordic countries. The Nordic countries were poor until relatively recently and have always been rather small. Certain welfare- and health-related questions arose as part of local small-scale systems for dealing with poverty but also, especially after the Second World War, as part of a larger welfare state project. Stenius’ account thus stresses the circumstance that work with questions of alcohol and drug use have in the Nordic countries at the outset of their first institutionalisation, already been inherently invested with thoughts on inclusion or social equality, things that have been lobbied for under the health concept in other geographical regions. The current shift to a health framing risks disentangling these questions from their original structural seating and signification. My own fear is a protectionist one: it is that today’s political influencers and decision-makers – whether they are scientists, politicians, or civil servants – have a blind spot when it comes to understanding that the adaption and importing of concepts and modes of operating may potentially dismantle our welfare state ethos.

The poverty and the small scale of the Nordic countries were, together with a strong central-local administration (especially in Sweden), the reason why people’s health measures became part of control measures for “changing peoples’ behaviour”. These were not behaviours that necessarily related directly to health, but they entailed also other aspects of wellbeing. The use of the concept of public health in political struggles and negotiations has not been as evident in the universalistic Nordic welfare culture characterized by a political consensus that tends to prioritise collective interests.

The epistemic context

In the Nordic countries many epidemiologists in alcohol research are trained in social sciences. Also, prominent sociologists such as Kettil Bruun and Klaus Mäkelä were alcohol (and drug) researchers. In fact, of the Finnish social scientists in the baby-boomer generation, almost all have at some point been involved with alcohol research. This is due to the alcohol monopoly system that would not only channel resources to alcohol research, but which also hosted the alcohol research unit. British and American colleagues are often surprised that so many Nordic alcohol epidemiologists have training in sociology, a discipline that has not profiled itself as particularly concerned with statistics for example in the UK.

In the final text of this discussion, Robin Room takes on the question of how the fields of alcohol and drug research have been related to disciplines and academic contexts (Room, 2018). On at least two occasions, I have myself in this journal tried to push the burden of blame for the lack of closeness with the social scientific core disciplines back into the field of alcohol and drug research (Hellman, 2015, 2018). However, Room accounts for a near history that also bears witness to a certain unwillingness on the part of universities to connect curricula, chairs and professorships to this thematic trait. Not even in sociology, a discipline with the most visible fetishism for epistemic compartmentalisation, are there established traditions with rubrics such as alcohol sociology or addiction sociology. Substance use and addictions are usually tied to sociological traditions through consumption sociology, political sociology, health sociology, or themes of marginalisation, poverty or social demography more broadly.

An important aspect that Room points out pertains to the closeness of public health to political action. Public health is indeed a field that justly prides itself on an activist history of solving societal health problems, such as tobacco smoking. This closeness with action may also have become an obstacle for dealing with more nuanced framings of matters, suggests Room. This statement links nicely to Sulkunen’s (2018) argument of the two sides of the public health coin: yes, it might in many senses carry an inherent justification of urgency and importance. However, it also tends to draw matters into a certain mode of action-oriented political argumentation traits: singular proof production is repeated in order to build up evidence bases, after which the proof is communicated and negotiated politically in order to act in evidence-based ways. To emphasize only this evidence-action trait may lock questions into a political culture that is unnecessarily stakeholder-based for universalistic and consensus-based political cultures.

As a caricatured description one can say that in the political climate of a social democratic welfare state the declarations of agendas are often intertwined with existing state institutions and, as such, partnered with a structural collective conceptualisation of possible action. Furthermore, the state is young enough to involve a certain level of self-evident belief in evidence production from its outset and thus has a certain level of knowledge production inherent in its machinery. Crudely put, the shift from a social democratic model to the stakeholder- and question-based political cultures that are typical for examples in countries with strong governance through rule of law and courts (such as the US) can be described as a shift from a political argumentation culture of “yes-yes-but how?” to a singular question-based “yes or no” struggle. The new alcohol act debate in the Finnish parliament this winter could for example be compared to earlier debates in view of such a political/cultural epistemic shift.

To conclude, the discussion section in this issue of NAD gathers thoughts that may give hints of aspects that lose out in case public health swallows the field of societal alcohol and drug research. These pertain to a collective grasp that embeds welfare institutions and focuses on systems and their implications. Also, the public health grasp may convey an intrusion into the unique Nordic epistemic closeness between social scientists and alcohol and drug research. Both quantitative and qualitative research may lose out: the Nordic social science epidemiologists are, with their training in, for example, sociology, in fact a rare species and, epistemically, a direct outcome of how questions of alcohol and drugs in the Nordic countries have been ordered on political agendas. They are not only health and demography statisticians but also (social) alcohol policy experts. Qualitative alcohol and drug research may lose due to its necessary reliance on social scientific theory and its closeness to academia.

This discussion section constitutes a very superficial scratching on the surface of a massive question with many entangled traits. At times the reader will recognise glimpses of other phenomena, such as the social dimensions of public health, the positivism of the Nordic welfare state, or the mainstreaming project of global health. In addition, there are bound to be readers with completely other views on the matters. At the journal we hope that this section will inspire further discussion.