Can public health be helpful in achieving independent living?

By Chris Hatton

What has public health ever done for disabled people? A pertinent question, given the almost complete ignoral of disability within the public health community to date. Yet, like the People’s Front of Judea (“All right, but apart from the sanitation, the medicine, education, wine, public order, irrigation, roads, a fresh water system, and public health, what have the Romans ever done for us?”), I believe the potential of public health to contribute to the independent living project is considerable.

First, public health is explicitly concerned with setting the conditions for people to get on with living healthy, fulfilling lives. The Judean People’s Front list are pretty much all legitimate arenas for public health intervention, and are seen as the essential conditions for communities to flourish. What are the essential conditions needed for communities of disabled people to flourish? This is a question far beyond this blog, but whatever they are I suspect they will be intelligible to public health, and would benefit broader communities beyond communities of disabled people. This approach also puts ‘choice’ (as distinct from self-determination) into proper perspective – ‘choice’ is not the end or even the means for most public health interventions that have the biggest impact on populations (do we ‘choose’ to have clean water coming through the taps?).

Second, public health is concerned with the totality of people’s environments and communities, using an expansive view of ‘health’ that legitimates public health interventions far beyond ‘services’ (and is a long way from medicine).  How environments facilitate or hinder fulfilling, healthy lives (for example, public spaces viewed as ‘safe’ from crime promote more social activities amongst citizens) are a central public health concern, and significant investments have been made in area-based initiatives that aim to empower local communities to decide their own strategies for improving their neighbourhoods. Such initiatives (although disabled people have been remarkably absent in the reporting of them) have the potential both to promote an inclusion agenda based on solidarity between disabled and non-disabled people, while also working to improve the neighbourhoods within which disabled people are included. Not incidentally for independent living, this view of health is inherently relational rather than individualistic.

Third, public health is explicitly concerned with social justice. Margaret Whitehead’s definition of health inequalities refers to differences in health status between social groups ‘which are unnecessary and avoidable but, in addition, are also considered unfair and unjust’. This explicit emphasis on achieving social justice, together with the recognition of the centrality of socio-economic position (in terms of poverty, hardship and employment, but also in terms of the impact of people’s awareness of their position in socio-economic hierarchies) should be fertile ground for the independent living project, and there are some glimmerings that public health may be starting to pay more attention to disability as an important factor intersecting with other dimensions of inequality (e.g. socio-economic position, gender, ethnicity) that are the traditional preserve of public health.

Fourth, public health has a powerful ‘spirit level’ argument (with compelling data) that inequalities within societies are bad for everyone, not just those at the bottom of the socio-economic pile. This has the potential for disabled and non-disabled people to make common cause in a campaign to make society more equal – not from a position of disabled people being vulnerable and therefore requiring extra ‘care’, but as common citizens where meaningfully supporting the self-determination of disabled people is part of a project to improve society for everyone. There is the potential to push beyond a narrow conception of ‘reasonable adjustments’ (where the mainstream adapts its practices) to a more expansive view where the mainstream is routinely designed to work for everybody.

And last but by no means least, in England the beginnings of an infrastructure (with public health based in democratically accountable local authorities through Health and Wellbeing Boards) is emerging. Pragmatically, these are new, still finding their feet, and potentially receptive to new thinking and to alliances that will help them to achieve public health goals within communities and neighbourhoods. Perhaps it’s time for a conversation?

About the author

Chris Hatton is an academic at the Centre for Disability Research, Lancaster University, UK, and also currently a Co-Director of Improving Health and Lives, the Learning Disabilities Public Health Observatory, part of Public Health England. His research work over the past 25 years has mainly focused on people with intellectual/learning disabilities, particularly around documenting the inequalities experienced by people with intellectual disabilities and their families and evaluating policies and practices designed to reduce these inequalities. He blogs here in a personal capacity. You can follow Chris on Twitter: @CHRISHATTONCEDR

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