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Community genetics or public health genetics?
  1. Johan P Mackenbach
  1. Correspondence to:
 Professor J P Mackenbach
 Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, Netherlands; j.mackenbacherasmusmc.nl

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The current debate on the terms “public health genetics” and “community genetics” is timely because it provokes thought on the values embodied in the usual methods of public health.

The history of public health is full of words: words defining the area of work, words that are then endlessly redefined or replaced by new words, and old words that come back into fashion again. Think of terms like “social medicine”, “social hygiene”, “community medicine”, “public health” …. The name of this very journal illustrates some of the terminological evolution as it has occurred in Great Britain. It started in 1947 as the British Journal of Social Medicine, at a time when the 19th century term “social medicine” had been revived. “Social medicine” was then perceived to have more positive connotations than the term “public health”, which had become associated with old fashioned hygienic practices. The journal first changed its name into Journal of Preventive and Social Medicine in 1953, and then became the Journal of Epidemiology and Community Health in 1978, after “community medicine” had replaced “social medicine” as the name for the British public health profession.1 Although the journal has wisely not changed its name a second time, “public health” is again the preferred term in Great Britain, as well as in many other countries, and has largely recovered its positive connotations.

But not among everybody. In a recent editorial in Community Genetics, Professor Leo ten Kate rejects the term “public health genetics”, and proposes to use “community genetics” instead, because the second refers to values that are not safe with the first.2 The term “public health genetics” has been introduced to denote the interface between genetics and public health, and is used in titles of training courses and names of research groups. It reflects attempts of the public health profession to cope with, and make best use of, the rapid advances in genetics. Genetic tests can, for example, be used in screening programmes for disease or for targeting health promotion interventions.3 “Community genetics”, on the other hand, reflects attempts of clinical geneticists to apply their counselling methods to the whole population. According to ten Kate, clinical genetics embodies a non-directive approach that is badly needed when genetics is applied at a population-wide level. The public health approach is seen to be too directive, and to have an undue focus on achieving health gains for the population as a whole, instead of helping individuals to make autonomous choices, for example, when it comes to the reproductive options that they face when presented with genetic information.

Even though the contrast between the two approaches may be somewhat of a caricature, this is an interesting debate, because it forces us to reconsider the values embodied in the usual methods of public health. What characterises public health is a focus on improving population health, instead of on the health of the individual who may or may not come into contact with health services. This leads to a preference for collectively organised interventions that actively try to reach everybody in the population, and a reliance on quantitative information that guides interventions in such a way that population health gains are maximised. Often, public health interventions are characterised by a certain degree of paternalism, and the value system of many public health professionals may indeed not be centred around protecting and increasing the individual’s autonomy.4

But that is changing, for example in the area of health promotion where community based approaches have been developed that aim to reach health goals through empowerment of people, and in the area of screening where strict rules for implementation have been developed that emphasise informed consent. Recently developed ethics codes such as those of the American Public Health Association also reflect an increasing awareness of the necessity to strike a careful balance between individual autonomy and collective values.5 Let us not forget that public health’s emphasis on collective action is driven by a desire to achieve equal access to effective health interventions, and that effective applications of genetics also deserve equal access, even when reproductive options are involved. Nothing is wrong with public health genetics—but it is good to listen to our critics and to reflect on our value systems.

The current debate on the terms “public health genetics” and “community genetics” is timely because it provokes thought on the values embodied in the usual methods of public health.

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