Public health: what is it?

by revere, cross-posted at Effect Measure

A couple of ideas are floating around in the comment threads as part of an initial conversation about public health. I’m not surprised they seem to be on different topics and have the feel of talking past each other.  We are not used to discussing basic assumptions and have an immediate tendency to talk about what we know, what interests us particularly, what bothers us most or what is our particular preoccupation.  Many of those things turn out to be really important for public health and there are plenty of reasons for talking about them.

Annie, for example, is frustrated with other medical and public health professionals.  From appearances she is herself a dedicated public health professional and feels alienated from her peers.  Like other professions we have become guild-like, with all the usual tendencies to draw lines around what we do, lines that keep others out.  The Association of schools of Public Health is now promoting certification exams, a very bad idea in my view. Who should get certified? As commenter/economist floormaster squeeze observes, the community’s health is tightly tied to the general state of the society, both economically and socially.  By that definition there are a whole lot of people “engaged in public health” that don’t fall under the usual disciplinary titles and even more who do day to day work that contributes significantly to public health (like the RotoRooter guy or the water treatment plant operator or the cop on the beat). I’m not advocating expanding the definition of public health so far that virtually everyone falls under that heading, but I am suggesting we start to think hard about what could properly and usefully be brought under the ambit of public health and what should not.

For example, commenter rotatingmass (RM) remarks that a major change from the early days of modern public health is the inclusion within public health of access to care, its financing and its administration.  It is not a minor point.  Health services has become the preoccupation, resource hog and motor of much going under the name of public health today, and RM wonders if public health might not benefit from a divorce.  Question: what would that leave, what should be included that isn’t, what should be further amputated from public health? Maybe it would be useful to shuffle some things like bioterrorism response into public safety, keeping pandemic response for public health and acquiring meteorology.  Maybe not.  There are trade-offs here and we should be discussing them openly and honestly, including the pros and cons.

As usual, DemFromCT makes an important point.  We need new models.  But a model of what?  New models aren’t likely to come only (or at all?) from within public health.  We are inviting another kind of engagement in public health, the engagement of the hivemind.  If you don’t think of yourself as a public health expert, you can still help think this through. Our thinking in public health has become ossified.  Don’t worry if you think your ideas are stupid or off topic. On the basis of blogging daily for four years (during which time I’ve had plenty of practice saying stupid and off-topic things), I’ll predict most of the ideas that will wind up in the comments will be at least uninteresting or off topic.  Try again. But some of them won’t be.  It’s the job of all of us to find the diamonds in the rough, separate them from the dust, cut some gleaming facets and polish the result.  A little bit at a time.

What, then, is this project we call “public health”?  One useful formulation of public policy is that it is what the community chooses to do for each other.  By that definition, if, as MRK expressed it in his comment, your objective is only to look out for yourself, then you aren’t engaged in public health (although someone else may be, on your behalf). But maybe it’s not a good definition. What would be a better one?

A lot of people have no patience for this kind of abstraction.  My advice is to come back later when we might have some of this sorted out.  But the difference between a conception of the bottom line that it is everyone for himself and one that says there are some things we will agree to do for each other is not trivial and deserves to be discussed, along with still other radically different views.  I strongly disagree with MRK on this (as on many other things), but I like very much that he decides to go directly for the jugular, what he sees as the core of the question.

What do you see as the core of the question? And what question?

Comments

  1. #1 Liz
    December 17, 2008

    Two important elements of the definition of public health are prevention and a commitment to social justice. Both of these conflict with the healthcare system in this country, which is focused mostly on treatment (rather than prevention) and is not accessible to all.

    The healthcare reform conversation we´re going to be having within the near future in this country has the potential to include more of a public health bent. The plans that are up for serious consideration all emphasize prevention and making healthcare more accessible to all. It´s easy for people to pay lip service to these concepts without actually doing much to advance them, so the public health community should get involved with the discussion and make sure we get more than vague promises.

  2. #2 revere
    December 17, 2008

    Liz: I happen to agree with both of your requirements for public health, but let me challenge you further. What, exactly, does “prevention” mean, why is it an essential part of public health, what (of the many possible things) should we be preventing, and why? (slightly different question than why is prevention essential).

    Now, social justice. I am for “social justice” as part of public health. But having said that, what exactly am I for? What does it mean, specifically in public health terms? Some people think that killing innocent people is a question of social justice. I can’t disagree. Until the “people” includes fetuses.

    Maybe we feel satisfied without spelling this out, but I suspect the main reason we wouldn’t is because it’s too hard. And that should tell us something.

  3. #3 Liz
    December 17, 2008

    Good questions, revere, and I agree that we should spell out what we mean, even though it´s hard. Some thoughts (which are by no means complete definitions):

    There are plenty of examples I think of when I reference prevention – clean air, water, food, and workplaces to prevent diseases ranging from cholera to asbestosis; vaccinations and hygiene measures to prevent the spread of infectious diseases; and environmental, behavioral, and medical interventions to promote healthier lifestyles that can reduce the risk of cancers and chronic diseases.

    A lot of us in public health tend to emphasize that prevention can be cost-effective when done right, because economic arguments are often important for getting programs or systems established. Our country obviously wouldn´t have enjoyed such impressive economic growth over the past couple of centuries if we hadn´t established water and sanitation services. Leaving depression and other chronic health problems undertreated (as is often the case when so many are uninsured or underinsured) is currently costing us money in lost productivity, while limiting the spread of seasonal flu can reduce costly sick days.

    There´s another reason to support prevention, and this starts getting into the social justice side of things: Preventing disease – and practicing secondary prevention, which minimizes diseases´effects – improves quality of life. Someone with untreated dental problems may be able to show up to work and function because she´s taking high doses of painkillers. Her problems may not show up in official statistics, but she´ll be miserable, and that shouldn´t be acceptable in a country with as much wealth as this one.

    As far as social justice, I have a tendency to define this in terms of correcting current injustices – worse pollution and a lack of healthy food in low-income areas, difficulty accessing healthcare providers for poor and minority populations, etc. Public health advocates work to reduce and eliminate this kind of inequality. We should probably state our definitions in positive terms, though, so I suggest that social justice is, at least in part, ensuring that all people have the opportunity to live healthy lives and be ableto provide for themselves and their families.

    This is a more detailed description of what I´m thinking about when I reference¨prevention¨and ¨social justice.¨ What else is missing to make complete definitions? Other people must have some thoughts, so I encourage all of our lurkers to weigh in!

  4. #4 martha
    December 19, 2008

    As you gather more material to further define public health, please include mental health. According to the Zogby poll in September 2007, 37% of us have been bullied in the workplace. This is the most painful and corrosive experience anybody in our group has ever had, with loss of career and finances having a domino effect on the rest of one’s life. 37% is a lot of people.

    With each case of workplace bullying there is a disturbance to all of the Target’s relationships. Family, spouse, children, etc. experience big bummers all originating with a cruel mistreatment that social scientists say has more in common with the psychology of domestic violence and torture than any legitimate business practice.

    Please join with us to help us make the facts available to the public. The damage includes severe physical issues like bleeding ulcers and cardiovascular problems. Workplace bullying can cost you not only your job, but your ability to do any job in the future. Some people are too sick to ever return to work.

    Thanks
    http://stopthebullies.home.comcast.net

  5. #5 Ban Asbestos
    January 13, 2009

    Martha you have my vote.