The case of palliative care and public health

Published on: Author: Sandy Whitelaw Leave a comment
Dr Sandy Whitelaw in front of a stone building

The eventual publication of our paper ‘Palliative care and public health: an asymmetrical relationship?’ in Palliative Care: Research and Treatment offers a chance to reflect on what ended up being a drawn out and rather tortuous academic process.

Over two years ago, David Clark and I started to talk and write about the engagement between ‘palliative care’ and ‘public health’, as expressed within a growing number of policy documents and academic articles. My own interest came from an awareness that policy makers, practitioners and politicians are increasingly saying ‘we need to adopt a public health approach to …’  any one of a long list of health or social issues. A preliminary review showed that these areas include drug misuse, obesity, HIV/AIDS, homelessness, climate change, knife crime – even bed bugs.

Despite an enthusiasm for this approach, we felt that the tendency to explicitly link public health to such topics had been under-examined and required more critical scrutiny. Deciding to use palliative care as a case study, we proceeded to draft a journal article that would explore this in more depth.

We began to realise  that rather than being ‘natural’ and ‘obvious’, the relationship between palliative care and public health is in reality based on a series of constructed steps that seek to ‘normalise’ the association. We also saw that the articulation of the relationship is relatively rudimentary and appears to have emerged as much for symbolic as pragmatic policy reasons.

To us, the relationship also felt asymmetrical. Whilst those in palliative care appear captivated by public health, the dearth of expressions of palliative care interest in public health discourse suggests a lack of reciprocity.

Our conceptual struggles were soon matched by other problems.

One by one we submitted the piece to no less that three journals in turn,  and each time received a rejection. All had positive (and perhaps polite?) things to say. For example, our article was considered “thought provoking” and “challenging”, offering critical views that “should be shared”. But ultimately we failed to pass the acid test of peer review with these journals.

The submission was challenged in two ways. Technically, our search method was considered not robust enough to provide “evidence” that would allow our claims to be “substantiated”. In a deeper sense, it was felt that our critiques had “already been answered” and such scepticism was unnecessary in a context where public health is fundamentally useful.

Now, these points could be seen as having some legitimacy and we did try to take them into account in later drafts – particularly, firming up our search strategy as a formal ‘mapping’ review. However, we believe the comments we received reflect deeper issues.

First, they highlight a tension between the need for a strictly formal approach to literature review coupled with a more pragmatic approach to discovery. We feel that in this case the latter was sufficient in creating a body of work that allowed us to reflect on the palliative care-public health relationship.

Second, they suggest deeper questions about the status of critical perspectives within affirmative and favoured policy narratives. It is understandable that anyone striving to develop informed and effective policy and practice would look to deploy available ideas and resources, particularly (if as might be argued of ‘public health’), they are seen as progressive. At the same time, we believe that there is a real danger of such ideas becoming what Frank Baumgartner and Beth Leech term a ‘policy bandwagon’.

We believe that the point at which ideas become ‘taken for granted’, is the very moment when they require critical scrutiny.  So, with gratitude to the journal that (after further revision) did accept it, we offer this paper in that spirit and as one contribution to the continued evolution of a palliative care – public health interaction.

Dr Sandy Whitelaw

‘Palliative care and public health: an asymmetrical relationship?’ in Palliative Care: Research and Treatment’

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