Community Health Sciences: A Distinct Field That Matters Now More Than Ever.

Community health sciences (CHS) is a distinct and essential field—yet defining it is challenging. How might we do so?

Prominent features that define CHS include: a focus on community and social context; interdisciplinary (see Table 1); the integration of many quantitative and qualitative information sources; going beyond observation to understand implications in order to challenge findings and apply them; collaborating and engaging with the community; and advocacy to improve health and health equity.

Does CHS matter? One way to answer this question is with a thought experiment suggested to me by a faculty member: What would public health look like without CHS?

Public health advances we would not have seen without CHS:

• John Snow and the Broad Street pump: Snow used epidemiological methods to identify the likely risk factor for cholera (water pump handle), but other methods, including community engagement, identified the “upstream” cause (diaper, leaky cesspool). Only the involvement of a key community leader with a different understanding of the issues convinced the public to do something about it.
• Ignaz Semmelweis observed common practices around childbirth to try to understand why so many women were dying of puerperal fever. The numbers told him it was more common when doctors (versus midwives) attended the deliveries (read: risk factor). After he tested several incorrect theories, he proved that physician handwashing after autopsies with a chlorinated solution reduced it. But he did not engage the relevant communities successfully, and many women died unnecessarily until his findings gained acceptance many years later.

These two seminal public health advances show the historical importance of CHS. But germ theory is old hat. What about today?

We now know that even the most individual determinants of health that one can imagine—for example, single gene mutations that cause sickle cell anemia—do not entirely determine an individual’s health status. How severe the disease is, the long-term course and prognosis, how the pain is perceived, how the illness is experienced, and much more is determined by community context, behaviors, and other social factors. So when we want to understand health, we look not only at genes and molecules, cells and organs, but also at relationships, health organizations and systems, community organizations, jobs, and all of society (known as the social ecological model). We know that the individual is embedded in and essentially inseparable from community. Thus health is a product of community, and we have sciences that are particularly good at sorting all of that out.

Topic areas addressed by CHS are the leading causes of morbidity, disability, and mortality of our time (see Table 2). But a mere listing of conditions belies understanding of a unifying thread: the need to view these conditions as occurring in people in communities (as ASPPH notes, the use of a “community lens”). We know it is simply impossible to address, in any meaningful way, the problem of addiction by providing individual counseling alone. We know it is impossible to address the obesity epidemic without addressing child health and access to healthy (and unhealthy) food. We know it is impossible to address gun violence deaths without understanding violence more broadly in a community.

So how does the academy define CHS? Although CHS is not defined by a single source, several sources are relevant. The Association of Schools and Programs of Public Health (ASPPH) defines community health as the health characteristics of populations within a shared geographical area, a view of health through a framework of community structure. Specific sciences are not mentioned, but examples of topic areas are noted and they include: “health education and community promotion,” “food nutrition, policies and interventions,” and “violence and injury prevention.” ASPPH places behavioral and social science in a separate category and lists some CHS-relevant topic areas separately (e.g. maternal and child health). The Council on Education for Public Health includes CHS by mentioning its recognizable elements as foundational knowledge (see Table 3). An informal survey of schools of public health in the US finds that three (Boston University, University of Illinois, University of Los Angeles) have departments called “Community Health Sciences” (and University of Las Vegas has a School of Community Health Sciences). Other schools appear to address this science in departments with related names (see Table 4). Thus CHS, while not always specified as such in the academy, features prominently throughout public health curricula and in the organizational structure of schools of public health.

CHS is a distinct field that matters now at least as much or more than it ever has, since it is the way to improve the health of people and their communities. CHS is not all of public health—other public health fields may focus on data, risks, and specific quantitative methods, or look through policy, environmental, or global lenses. CHS is a scientific field that draws on many other sciences and integrates them. It focuses on community (a community lens) and social context to understand findings and apply them in collaboration with communities to improve health. Recognizing that this field is at least on par with sciences that have identified disease risk factors in databases is critical to actually improving the health of people and communities. A member of my faculty summed it up well: “We do stuff with the information we learn.” At the School of Public Health, the common stated purpose is “Think. Teach. Do. For the Health of All.” We in CHS put the “Do” in that statement.

Special thanks to community health sciences faculty who contributed to a preliminary conversation: Angela Bazzi, Judith Bernstein, Candice Belanoff, William DeJong, Carol Dolan, Trish Elliot, and Emily Rothman.

Richard Saitz is professor and chair of community health sciences.