Avoiding Death on the Highway and Other Public Health Benefits of Clear Writing.

Muddiness is not merely a disturber of prose, it is also a destroyer of life, of hope; death on a highway caused by a badly worded road sign, heartbreak among lovers caused by a misplaced phrase in a well-intentioned letter, anguish of a traveler expecting to be met at a railroad station and not being met because of a slipshod telegram. Think of the tragedies that are rooted in ambiguity, and be clear! When you say something, make sure you have said it. The chances of your having said it are only fair.

William Strunk Jr. & E.B. White, The Elements of Style

Every semester, I ask my students to read The Elements of Style and inevitably find myself pausing at this passage and talking about my late colleague, Professor Bill Bicknell. Bill had a way with words, and he took great pleasure in startling students by saying things like “public health is the art and science of deciding who dies, when, and with what degree of misery.” He also liked to talk about how public health done badly can sicken or kill thousands, whereas medicine done badly does its damage one-by-one. He was talking as much about careless or arrogant communication as he was about poorly executed interventions or wasted resources.

So take a minute to imagine the road sign designed to improve safety on a busy highway but instead creating chaos, and the split second of misunderstanding that leads to a multi-car pileup. Then think about all the other ways thoughtless, murky, or overly abundant language can lead to unintended, negative public health consequences. I am being dramatic, as were Strunk and White, so here is a more prosaic example. Which of these sentences would you prefer to read?

• According to the World Health Organization, prevention of mother-to-child transmission of HIV using lamivudine provided by healthcare workers during antenatal care, labor and delivery, and breastfeeding improves immunity and overall health outcomes for HIV-positive women and their neonates.
• According to the WHO, PMTCT using 3TC provided by HCW during ANC, L&D, and BF improves CD4 counts and overall HO of HIV+ PW and their NN.
• Pregnant women with HIV can improve their own health and protect their newborns by taking medication during their pregnancy and while breastfeeding.

Sentence one is long and jargon-filled. The wording is reasonable if your audience understands the terminology, but it could certainly be more engaging and succinct. Sentence two is ridiculous, but not far off from many I have read. Sentence three is clear and to the point, but to some will seem simplistic. Depending on your audience and intent, it may be. The Dean’s Note on “The Language of Public Health” is an important reminder that the critical first steps of effective communication are: having a clear objective; knowing your audience; and molding your language, syntax, and style to the interests and needs of your audience.

Writ large, the field of health communication seeks to change social structures and policies, community norms, and individual thinking and behavior. It entails everything from public service announcements to congressional testimony, road signs, and articles in Public Health Post or the Boston Globe. It is communication at the macro level. But game-changing public health research, advocacy, and behavior change campaigns start much smaller, often with a single person sitting at a keyboard, plotting arguments, marshaling evidence, and painstakingly dwelling on words, phrases, sentence structure, and transitions. The work of public health is very much a team sport. So we sometimes lose sight of this solitary figure and don’t leave as much time as we should in our classes to talk about strategies for becoming a better writer.

I would like to bring this lonely writer forward and encourage a community conversation about what we are asking students to do when we assign papers, and how we can best support them as they learn a new language and genre. As faculty, we cannot assume that students come to SPH knowing how to write clearly about complex public health topics, what a policy brief is, or what language will be most effective with Boston Mayor Marty Walsh versus the New England Journal of Medicine. All students have the potential to develop strategies that will help them become better writers. Together we can foster a culture that values clear, precise communication as a core instrument, function, and goal of public health.

So, what are the critical messages about writing our students need to hear?

All students need to devote time and care to practicing and improving their writing during their short time at SPH and over the course of their careers. Even the best writers need to approach writing with humility, patience, and perseverance. A fundamental premise of composition theory is that any attempt to help a student improve their writing must focus on the writing process as much as on the product. From this perspective, learning to write clear, factually correct, convincing prose is a lifelong endeavor. It is not a discrete skill, like learning how to use a 2-by-2 table or interpret a confidence interval, learned once and thereafter easily applied.

Our students come from a wide variety of disciplinary, cultural, and linguistic backgrounds. So we cannot assume they know the language and typical formats of public health writing. It is our obligation to give them opportunities and constructive feedback to build these skills. If that means reminding them that they need a thesis statement and topic sentences, so be it. Sometimes the most basic structural components of professional and academic writing fall away when an author is struggling to understand new concepts, integrate complex or even contradictory evidence, or find a way forward in a haze of ambiguity.

Some Thoughts for Students

Strengthening your writing skills during your time at SPH is as important as learning how to calculate a p-value or write a SAS program. In response to a 2016 survey conducted by SPH, 63 percent of alumni said that communicating public health messages is a skill they use always or often. This survey was also distributed to public health organizations that employ SPH graduates. Almost all employers (98 percent) confirmed that writing and editing reports is an important or very important skill. More than two-thirds similarly highlighted the ability to sell or convince others. Another one-third said they are likely or very likely to be recruiting staff for communication positions.

With this in mind, I urge you to approach each writing assignment as an exercise in intentional or deliberate practice rather than as a demonstration of innate ability. Start early and use the resources provided by the SPH Public Health Writing Program, which include a detailed Public Health Writing Guide, library tutorials created by librarians from the BU Alumni Medical Library to help you find the most relevant and reliable sources, and our team of dedicated peer coaches who will provide feedback on your drafts. Work with the peer coaches even if you think of writing as one of your strengths. Your chances of saying what you mean in a clear way that engages your audience will improve with each draft you write.