Disease causation and public health interventions
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This document discusses the relationship between conceptual frameworks in public health and normative questions about appropriate policy interventions. It argues that conceptualizations of disease causation, like considering social factors as proximate rather than just distant causes, have implications for what public health actions should follow. The document uses the example of conceptualizing obesity to argue that philosophical work on concepts can influence values and promote certain policy approaches. It concludes that philosophical analysis is fundamentally important not just for foundations but also for determining appropriate actions, and that the societal relevance of philosophy extends beyond what is often recognized.
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Disease causation and public health interventions
- 1. Disease Causation and Public Health Interventions The Entanglement of Conceptual, Methodological, and Normative Questions Federica Russo Philosophy | Humanities | Amsterdam russofederica.wordpress.com | @federicarusso
- 2. Overview Cross-cutting and domain-specific questions The health sciences and public health Domain-specific questions to be address with cross-cutting concepts: conceptualising health&disease Concepts and actions What policies should follow from specific concepts? On the non-neutrality of philsci How do concepts promote values? 2
- 4. The distinction Cross-cutting questions How do we explain? What are causes/effects? When is an experiment/model/method valid? … Domain-specific questions What are genes? What is Higgs mechanism? What is agency? What is a pathology? … 4
- 5. Still worth distinguishing? Yes, to foster unity of philsci rather than crystalise fragmentation Yes, to precisely pinpoint where value-neutrality philsci falls short 5
- 6. Health sciences and public health 6
- 7. New special sciences Recent additions to the range of options A long process to legitimise interest in them What’s so interesting, then? Methods: experimental, observational, data/technology-driven, … Concepts: health-related, borrowed from bio-chemistry or social science, … Actions: diagnosis/prognosis, treatment, public health interventions, … Contextualisation: historical, cultural, political, … 7
- 9. A domain-specific question Essential to the field, and with its own tradition What is normal and what is pathological Biologically, statistically, experimentally, socially, politically, historically, … Dimensions of the question Metaphysical, Epistemological, Methodological, Normative 9
- 10. Cross-cutting concepts for health&disease I tackle a domain-specific question using cross-cutting concepts Scientific practice first How do we study health&disease? What are the causes and mechanisms of health&disease? {What is X} is answered by {How we study X} Yes, I derive metaphysics from epistemology 10
- 11. Causes & mechanisms of health & disease Several types of practices in the health sciences Biomedical research; clinical practice; EBM; narratives; (public health) interventions; … Variety of practices to study what makes us healthy/sick Here: practices in which we causally understand health&disease by studying biological and social factors 11
- 12. Descriptive and normative Descriptively: plenty of research to establish correlations <social social factors--health&disease> Normatively: social factors are active causes in the mechanisms of health&disease We need a concept of causation/mechanisms that accounts for the mixed nature of health&disease Social factors are proximate, not distant causes 12
- 13. Bio-social causes of health&disease Historically, 19th century public health is much about social factors Recently, characterised as ‘the causes of causes’ Sociology of health / social epidemiology Health&disease are associated with social factors Inequalities in health are associated with inequalities at the social level Health&disease happen in a social context 13
- 14. The mixed bio-social nature of health and disease Established and vast research traditions The bio-chemistry of health and disease The social nature and effects of health and disease How to combine them? Not just social determinants, distant causes, or ‘causes of causes’ Social factors are active, proximate causes in bio-social mechanisms Easier said than done Some research in this direction exists (e.g. Lifepath project) But it needs further conceptualization and methodological tools 14
- 15. What is a bio-social mechanism? A ‘minimal’ definition of mechanism (Glennan and Illari 2017) “A mechanism for a phenomenon consists of entities (or parts) whose activities and interactions are organized so as to be responsible for the phenomenon.” It is minimal because meant to be wide applicable across scientific contexts Mechanisms of health and disease are bio-social Entities and activities can refer at once to biological and social factors, Both contribute to the phenomenon ‘Minimal mechanism’ doesn’t imply a thick and rigid entity-activity metaphysics, this minimal definition can be epistemic 15
- 17. A general argument IF we conceptualise X such-and-such THEN what actions should follow? Replace X by your favourite: health, evidence, probability, … Normativity is double Philsci concepts are non-neutral Philosophy is part and parcel of science/policy, not a cherry on the cake 17
- 18. The specific argument IF the social has active causal role in health&disease THEN what public health interventions should follow? 18
- 19. Obesity and food labelling An example 19
- 20. Social causes, biological interventions Obesity ‘epidemic’ Wide recognition of social factors (besides biological ones) Top priority for EU health policy EU announces to tackle social factors (e.g. behaviour) One of the biggest actions: regulating food labelling Ultimately tackles the biology of obesity Claims to target food industry, but in fact it makes info available and leaves the choice to the individual person Pulls in opposite directions with actions to improve on competitiveness of SMEs 20
- 21. Normative concepts Or, on the non-neutrality of Phil Sci 21
- 22. Concepts are value-ladenness Ladenness may have 2 directions: i. Values that influence our concepts/methods ii. Our concepts that influence the values we promote (i) is much more studied than (ii) 22
- 23. Value-promoting concepts ‘Health’ is certainly normative in the practice of public health But ‘health’ is also normative at the level of the scientific concept Whether social factors are proximate – rather than distant – causes makes a difference The methods we choose The actions we take 23
- 25. Social factors are proximate causes of obesity What to do with Food labelling? Food industry? Marketing? What consequences to draw from a concept that would (naturally?) lead to paternalist attitudes? How to reconcile it with (justified?) libertarian intuitions? Is a ‘libertarian paternalism’ a viable option? … 25
- 26. To sum up and conclude 26
- 27. Cross-cutting and domain-specific An old distinction, but worth using For conceptual clarity To foster dialogues between phil of different special sciences To achieve unity, if possible at all, or at least synergy Causality, evidence, explanation Cross-cutting concepts that can be used to ask domain-specific questions, e.g. about health&disease 27
- 28. Concepts and actions A causal conceptualisation of health&disease Social factors are proximate causes, on par with biological ones A controversial point on its own Despite the large body of literature on social factors and health More controversial still What actions should follow from this conceptualisation 28
- 29. What is often considered abstract, conceptual, ‘just’ theoretical work of philosophers is instead fundamental, not just for the foundations, but also for the actions that should follow “Leave me alone doing my philosophical stuff” does not work, and should be resisted There is a societal relevance of philosophy, well beyond what is often recognised, or even desired by many of us 29
- 30. Disease Causation and Public Health Interventions The Entanglement of Conceptual, Methodological, and Normative Questions Federica Russo Philosophy | Humanities | Amsterdam russofederica.wordpress.com | @federicarusso Thanks for your attention
Editor's Notes
- === In this talk, I discuss how concepts, methods, and values are entangled. While the argument can be applied widely across the sciences, I focus here on the sciences of health and disease, and on public health. In particular, I will show that different ways of conceptualizing (disease) causation are inherently linked to the methods (used in the health sciences) and to values (at work e.g. in public health). I will argue, on top of well-established arguments, not only that scientific methods and concepts are value-laden, but also value-promoting, and so any normative questions cannot be asked at the end or outside of the scientific process, but should be an integral part of it. === Contextualize this work: Public health gaining attention in phil sci community, not just from ethics perspective. I got to public health coming from causality / biomed / modelling. One reason to present this at DIEP is the interesting question of how conceptualizing of (disease) causation in different way has an impact on normative questions. Usually, argument is about value-ladenness, but here I try to reverse the order of influence: concepts PROMOTE some values rather than others. And so any work done at conceptual level IS very important. How this may connect to DIEP, will discuss later
- How to get to this point about the influence of conceptual work on normative Q? Step back: distinction btw cross-cutting and domain-specific questions. Focus on health sciences and public health, explain how, in my case, these two types of questions were tangled. Here we stay mainly at conceptual/method level. Explain how, I think extra layer of complexity arises: normative aspects are also entangled. Last part, discuss how we could set-up discourse on non-neutrality of phil sci and develop idea of value-promoting concepts.
- Distinction comes from neo-pos onwards Some gen philsci Q were actually about physics! E.g. about theory and explanation. Special sciences were special with respect to physics. Here I want to say that each sci discipline is special on its own grounds. Also, want to say that very likely domain-specific questions (partly depend) on answers to cross-cutting questions. And vice-versa. Will come back to this in a min, exemplifying with health
- On unity / fragmentation: Mention unity/disunity, see e.g. Shurz in book Unity/disunity à la Cartwright/Dupre I emphasise unity because I don’t want hierarchies and gold standards On value-neutrality Lots of literature on value in science. Sure. BUT WHERE do values come in?! Take H&D as an area where it is important to investigate where norms are tangled with concepts
- Go through these points, then: Growing interest in the community, and beyond EBM, likely! Notable example, specifically on public health –or rather population science– is Sean Valles book. In fact, Sean’s work is an excellent basis to ask the questions I raise later. They really build on them. Or see Galea and collaborators
- I am deliberately borrowing Canguillhem ‘normal and pathological’ as I can’t find a better expression to condense all these dimensions
- This is how *I* tackle the question Implicit: I take the study of causes-mechs at the core of science. NOT that this is the only thing they do, but what they aim for. Even descriptive / observational is instrumental to understand whats and whys. See e.g. Schramme on classic concepts of disease. OK to distinguish meta/epi/axiologic aspects. But it seems that these are intertwined!
- Why telling you all this? Because when I accepted Jay’s invitation, I had the dream of working on the idea that contrary to a biological model of H&D, H&D as bio phenomena *emerge* from the social ones. So more than putting them on a par, I’m going towards thinking that the order of priority is even reversed!
- See David Teira on evidence and drug safety!! David’s work really important and needs to be streamlined and extended! N.B. existing debate in epidemiology whether discipline ipso facto concerned with policy or not. Both views exist. Ultimately about whether epidemiologists should translate *results* into policy interventions. HERE: pose similar question, but at stage earlier than results >> concepts and methods
- Seems much needed. See chronic diseases that are preventable, still on the rise. Obesity epidemic. Even for infectious diseases, urgency may be related to underestimation of soc factors
- See again e.g. David’s work on evidence in drug regulation
- These questions often discussed from the perspective of autonomy and the role of the patient / citizen. See e.g. Boniolo on deliberative democracy and deliberation in biomed ethics Here: whether one should take sci-concepts to their (undesirable?) consequence?
- === In this talk, I discuss how concepts, methods, and values are entangled. While the argument can be applied widely across the sciences, I focus here on the sciences of health and disease, and on public health. In particular, I will show that different ways of conceptualizing (disease) causation are inherently linked to the methods (used in the health sciences) and to values (at work e.g. in public health). I will argue, on top of well-established arguments, not only that scientific methods and concepts are value-laden, but also value-promoting, and so any normative questions cannot be asked at the end or outside of the scientific process, but should be an integral part of it. === Contextualize this work: Public health gaining attention in phil community, not just from ethics perspective. I got to public health coming from causality / biomed / modelling. One reason to present this at DIEP is the interesting question of how conceptualizing of (disease) causation in different way has an impact on normative questions. Usually, argument is about value-ladenness, but here I try to reverse the order of influence: concepts PROMOTE some values rather than others. And so any work done at conceptual level IS very important.