The Aspirations and Strategies of Public Health
This Dean’s Note is co-written by Professor George Annas.
A few weeks ago, we published an essay called “Aspirations and Strategies for Public Health.” Here we reproduce some of the arguments in that essay, in extended form, simply because many of the thoughts therein seem directly relevant to our ongoing School discussion.
We start with a fundamental premise. Public health is responsible for extraordinary achievements over the past century and could make similar critical contributions to health in this century; this track record of success would seem to make public health the logical choice to address new challenges to life and health in a changing world, including chronic diseases, increasing income disparities, the threat of bioterrorism, and climate change.
Our worry, though, and motivation for this article is that despite these successes, organized public health appears to be on the defensive. Efforts such as the burgeoning precision medicine agenda and the continuing war on cancer have captured the imagination of both federal funding agencies and the highest level of politics, including the President, diverting resources in the direction of individualized efforts at disease prediction through genomic approaches, and away from the structural efforts that aspire to the broader population-based impact that has long characterized public health action. Our societal preference for dazzling technology that leads to expensive treatments rather than relatively inexpensive prevention measures threatens to monopolize the direction of public health scholarship for decades to come, given that much public health scholarship arises from academic public health institutions that remain heavily dependent on federal funding agencies. Public health shares funding and infrastructure deficiencies with transportation, education, and virtually all other endeavors reliant on public funding and leadership, and investments in much of this infrastructure have been declining, or barely keeping pace with needs, for decades. In this context, every extra dollar spent on medical care comes at a high opportunity cost that degrades our environment.
Why is this the case?
The challenge to public health does not center on disagreements about the core goals of the field, which have always been, and remain, broad and aspirational. The World Health Organization, for example, defines public health (and its goals) as “all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases.” This definition is echoed by several others, including in the Institute of Medicine’s 1988 Report, The Future of Public Health, which defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy.” According to the American Public Health Association, “public health promotes and protects the health of people and the communities where they live, learn, work, and play.” These descriptions all take to heart public health’s focus on creating conditions that enable healthier populations, with a key emphasis on preventing disease.
We suggest, rather, that part of the challenge has been public health’s embrace of a shift towards operationalizing what we do without sufficient recognition of our aspirational, purpose-driven mission. A well-articulated set of “essential public health services” in three categories of function: assessment (regular surveillance of the health of communities), assurance (making services available to the public), and policy development (using scientific knowledge) represents what we do. As a core set of foundational activities, these remain valid and reasonable today. However, maintenance of core functions and activities cannot in and of itself constitute a forward-looking purpose; rather, it suggests doing more of what worked in the last century in a rapidly changing environment. The director of the Centers for Disease Control and Prevention, has, for example, suggested that public health should “expand its past successes to further reduce tobacco and alcohol use, control persistent infectious diseases, increase physical activity, improve nutrition, and reduce harms from injuries and other environmental risks.”
This agenda is, in our assessment, too narrow, and is responsible for public health losing ground to medical concerns in the national conversation. The bold goals articulated in the definitions of public health will never be met, or even taken seriously, if public health itself abandons or severely limits them. Tension between the bold roots of public health and its uncertain operational manifestation has allowed public health to recede in collective consciousness, as a burgeoning medical agenda has moved to the forefront. A lack of clarity about public health’s purpose has also muddied its actions and depressed its aspirations.
So what aspirations can invigorate what we already do well and nudge us into areas of innovation? We suggest two aspirations that are informed by our understanding of the state of the field, the challenges it faces, and the threats to public health we see facing us going forward.
First, public health continues to be about the conditions that make people healthy, and thus must unstintingly engage the social, political, and economic foundations that determine population health. Although creating the conditions that make people healthy is universally acknowledged as a central goal by most prominent definitions of the field, it remains perhaps the most difficult purpose for public health to seriously grapple with. The challenge is that the conditions that make people healthy often are outside what we have historically considered the remit of the health professions. For example, there is ample scholarship that has documented the core role of both income distribution and racial segregation as drivers of population health. A focus on the conditions that make populations healthy requires entanglement with issues that reflect political and social structures. Such an engagement is freighted with peril, both conceptually and operationally.
Conceptually it is inevitable that engagement with broader social and political issues tangles with societal values and political circumstances that are far less value-neutral than are efforts at population health maintenance such as disease surveillance. Operationally, engaging with issues such as racial segregation in housing and education requires clarity of advocacy by the public health professionals who must, to be effective, work in areas such as media, business, and academia as well as in the governmental public health infrastructure. This puts public health in the position of attempting to quarterback complex social change, motivated by an understanding that absent such change, very little is achievable that can sustain the health of populations in the long-term. This will require a boldness on the part of public health, as well as the reliance on agents of public health action, such as universities, that are less beholden to political dicta in establishing their budgets and their operating constraints. It also requires engaging with two powerful new organizational forms that have concentrated power and influence in ways that directly affect population health: the transnational corporation, and the nongovernmental organization. These organizations have their own agendas, and global public health will not be able to succeed without accounting for, and influencing, their actions. For example, NGOs, most notably Doctors without Borders, dominated the treatment of Ebola patients during the 2014 epidemic, and airline corporations determined whether air transportation services would continue to be available, in what countries, and on what terms.
Second, public health must balance overall improvement of population health with the achievement of health across groups and the narrowing of health gaps. This challenges public health on multiple levels. Although the roots of public health are in line with efforts to promote health among vulnerable and marginalized populations, we have achieved mass legitimacy through an unstinting focus on improving the health of the aggregate, making populations healthier. This has, perhaps not surprisingly, diminished our emphasis on the health of marginalized groups and our intellectual engagement with the real consequences of such effort. It is not too far a line to draw from an embrace of overall health improvement as our goal to an acceptance of health gaps as an inevitable consequence of immutable social structures. Health inequities, however, remain at the core of the conceptual underpinning of why we in public health do what we do, and the drivers of these inequities are the same drivers that have animated some of the difficult national conversations that have resurfaced in the past few years. It stands public health in enormously good stead to be at the forefront of this national conversation, creating a unique opportunity for us to engage in the foundational drivers of health, and to change a national conversation around health, in the service of our aspirations.
Given these aspirations for public health, what are the best strategies to meet them? We suggest four that offer a way forward.
First, the breadth of public health engagement we suggest necessitates relentless prioritization, engaging both intellectually and pragmatically with the core question of what matters most to the health of populations. And this question is time-specific and subject to change. As Sir Geoffrey Vickers put it in 1958: The “critical and ubiquitous question [is] what matters most now?” (emphasis added). This embeds intellectual, practical, and operational complexities. Intellectually, our scholarship is frequently ill-suited to identify what matters most and has for many decades been prolific at identifying causes of ill health without much serious engagement in questions of prioritization or relative weighting. This will require a rethink of how we do our intellectual work and how that work intersects with the actions of public health. Practically, the challenge in engaging what matters most lies in the mismatch between what we may be able to do and that which may indeed have the greatest impact. Unfortunately, we have, as a public health profession, for too long erred on the side of pragmatism, focusing on smaller scale efforts—principally around engagement of lifestyles and healthy behaviors—at the expense of larger efforts that target foundational drivers. Only by using a conceptual lens that scrutinizes and evaluates our actions for their salience and contributions towards the larger goals at hand are we likely to make much progress in meeting our goals.
Second, we must actively engage the mechanisms that explain how core foundational structures produce population health. Therefore, while core social conditions—including, for example, the widespread availability of cheap, calorie-dense, nutrient–poor food—is undoubtedly the core driver of the obesity epidemic, health behaviors including eating patterns mediate the relationship between the corporate practices that establish food availability and obesity in populations. We ignore health behaviors at our peril. Nonetheless, public health cannot effectively engage eating behaviors without recognizing their place in a causal cascade. Eating behaviors do matter, but they matter only insofar as food choices proffer a range of options that ill serve the ends of health promotion. It is, however, easier to tackle the mediating mechanisms than it is to tackle the foundational determinants, in no small part because we think that the former fall within the scope of public health action, and that while we pay definitional attention to the latter, our action on it is limited. Therefore, this challenge centers on breadth of engagement, from the foundational through the mechanistic. It argues that we need to adopt a perspective that seeks balance, navigating the import of understanding and intervening on mechanistic processes, without losing sight of the core foundational drivers that will determine the sustainability of any progress. This thinking also applies to public health’s engagements with areas such as genomic medicine in terms of both scholarship and practice. It suggests that public health would do well to be a part of a conversation that engages the genomic research agenda and its potential, while recognizing it as one rather small piece of a much more complicated production of health of populations in which the environment, lifestyles, and even the microbiome are likely more important than genomics in determining health. Put another way, “personalized medicine” is not public health.
Third, the vision of public health as a government-mandated and financed activity has already been supplemented, if not replaced, by a wide recognition that public health is multi-sectorial and that we need to engage actors across government, academia, industry, and not-for-profit sectors, among others, to achieve the goals of public health. It is not as well recognized that these multiple sectors will engage around the goals of public health only if we create a narrative of the importance of public health that fluently replaces a current health narrative that centers on improving clinical care. Public health must be at the forefront of generating and sustaining a broad national and global conversation around centrality of population health to all our well-being. This will require substantial engagement in education both of our patterns across sectors and of a broader public that must see the goals of public health as consequent and important drivers of decisions across these sectors. It also requires the elevation of health in public consciousness and the recognition that individual health is glass ceilinged without an improvement in the health of the collective. Teachable moments such as the Ebola outbreak represent an opportunity to shift the public discussion towards emphasizing the foundational efforts that must be taken to create a world where Ebola outbreaks are prevented or quickly contained, rather than a world where we have tertiary hospitals and new pharmaceuticals to treat people who contract Ebola when large-scale outbreaks happen.
Fourth, public health needs its own ethics to help guide practice. The fact that much of public health is directed by the state—and often defines the relationship between the state and the individual—suggests that human rights, as articulated in the Universal Declaration of Human Rights, provides a solid ethical framework for public health practice. In practice, many in public health have already adopted human rights as the primary guide for their work. This is because not only do human rights proclaim a “right to health” for all people, they also provide a wide array of state obligations to “respect, protect, and fulfill” the rights of people in ways that promote population health. The World Health Organization has adopted the “health and human rights” principles, and, like the goals of public health itself, the challenge is not to define them but to apply them. Jonathan Mann, the first head of the WHO’s world AIDS program, suggested the “health and human rights” paradigm for public health at the beginning of the HIV/AIDS epidemic, when he quickly discovered that those with the disease were often severely discriminated against and lost jobs, housing, and even families as a result. His legacy, as Rebecca Cook and Bernard Dickens have suggested, is “his focus on how social inequality, economic powerlessness, social exclusion, and denial of human dignity condition preventable disease, disability, and premature death.” The universal scope of public health is matched only by that of human rights and, because of its core focus on human dignity and nondiscrimination, its inherent partner, social justice.
The potential of public health to continue to improve the health of populations is being challenged and undermined by multiple factors, including an overemphasis on curative medicine and increasing the length of life regardless of quality of life. The medical agenda is clear. A lack of clarity about the purpose of public health has made us less effective than we could be. We suggest that identifying two core aspirations and four strategies for public health can help shape our resolve towards public health achievement in the remainder of the 21st century.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/