Tuesday, March 13, 2012

Evidence of the fragmentation of public health perpsectives?

Plotinus, a "neoplatonist" believed that the ultimate good was a return to the "one" - the experience of the world in its holistic coherence, without fragmentation into silos and fragments defined by narrow human interests and perspectives.  I was reminded of this when I read two articles in the March, 2012 issue of the American Journal of Public Health - first
Project-Based Housing First for Chronically Homeless Individuals With Alcohol Problems: Within-Subjects Analyses of 2-Year Alcohol Trajectories by Susan E. Collins et al describing how providing housing to people with alcohol addiction problems, without requiring them to be abstinent of alcohol (as many welfare programs require) resulted in decreased alcohol use.  This was an example of ensuring the addiction did not stigmatise the user and further lower their living standards and reinforce their alcohol use.  

In the same issue, Michael Ong et al publish Estimates of Smoking-Related Property Costs in California Multiunit Housing in which they attempt (with a 22% response rate) to estimate the impact of smoking renters on property costs.  They calculate that "implementing statewide complete smoke-free policies may save multiunit housing property owners $18 094 254 annually."   

Logically  a smoke-free policy for renters will deny rental accommodation to many smokers who cannot quit. Most people with alcohol problems smoke.  So the policy proposed by Michael Ong and colleagues will likely result in more homelessness among the people with alcohol problems that Susan Collins et al are trying to house. 

The authors of these papers see and describe the world from vastly different perspectives and highlight the fragmentation of our public health "vision".  I am sure that both author groups have equivalent compassion for smokers and people with alcohol problems. But if you compare the approach of the two papers Susan Collins et al focus on directly benefiting  people with alcohol problems whereas Michael Ong et al focus on a benefit to landlords and taxpayers, with a secondary potential benefit to smokers who quit to gain housing.  These are starkly different perspectives.

Two thoughts - on the mundane or policy level - is this an argument for a total ban on the sale of tobacco rather than a partial ban based on housing with discriminates against those of lower socio-economic status with potentially dire unintended consequences?  On another level - can compassion guide us through the complexity of public health and the potential unintended consequences of system interventions. 

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