Blinders and Infrastructure in Public Health

The influential left-wing blog Daily Kos has been running a series called "Flu and You" by health blogger DemFromCT, and this week's installment features an interview with one of the reveres from Effect Measure, who often cross-post here. The whole thing is worth reading (as are the first and second parts of the series), but I wanted to highlight a couple of sections that echo back to the Progressive Public Health series that the reveres wrote last month as a call to the public health community to look critically at where we're going.

First, here's something about the difficulty of trying to organize in a school of public health (emphasis added):

I've spent many decades in academia, most of it in a major School of Public Health where I am a Professor and researcher and was a longtime Department Chair. I was an anti-war activist in the sixties and remain one today and because of that I've spent a lot of time organizing on peace and other justice issues within schools of public health and schools of medicine. My personal experience has been that it is much easier to organize in a school of medicine than in a school of public health. This sounds counterintuitive because students and faculty in schools of public health are intimately occupied with access to care, environmental contamination, the plight of our society's least advantaged and much else intimately connected to social justice. Many are passionate advocates for their particular specialty areas, like substance abuse or reproductive rights. In describing them, however, I have deliberately used the word "advocate" rather than "activist," because that's what they are. They work tirelessly and effectively for their particular area but quite often have blinders and little time for any other issue. Their area is the most important. The citizen preparedness advocate is often of this stripe (there are many exceptions, of course, but I am trying to make a general point). If you couple a tendency to cleave toward advocacy rather than activism (meaning a more general progressive political stance that crosses issue boundaries) with the fact that the main employers and institutions public health students identify with are in the public sector, it becomes understandable that mobilizing them against government actions on issues outside of their area of interest is not something that comes easily. Medical students, on the other hand, often feel independent, empowered and self confident enough to question government actions. They start out poorly disposed to the government in the first place and as students they are still idealistic enough so there is a reasonable yield of activists amongst them.

I think it's wonderful that public health recognizes that dozens of different factors, from environmental contamination to reproductive rights, affect our population's health. At the same time, that broadness seems to make it inevitable that public health advocates will sort themselves into issue-specific groups within the larger field. The question is, does belonging to a particular issue group tend to make people blind to the other issue groups -- or just too overwhelmed to participate in any other group's activities?

The other part of the interview that stood out for me was the discussion of public health infrastructure. One of the many things I appreciate about Effect Measure is the way the reveres keep reminding us that the best way to be prepared for any health emergency is to have a strong public health infrastructure. I never spent too much time thinking about what "public health infrastructure" actually referred to; I figured it meant health-related facilities, workforce, supplies, and the capability to use those elements. Here, revere explains not only why public health infrastructure is important, but that it may be more complicated than some of us assume:

Over at Effect Measure we've been saying for years that the best way to prepare for an influenza pandemic is not with antivirals or vaccines (although both have important uses) but by strengthening the public health and social service infrastructure to make it robust and resilient. Our view is that preventing a pandemic is technically difficult or impossible so the main task is to prepare to manage the consequences. The consequences of a large proportion of our population being sick or dying extends to almost every part of our society.

Itâs the Three Little Pigs principle. The piggiesâ mommy sent them out into the world to "seek their fortune," but the world is full of danger. The first pig invests little effort in getting settled and builds a house of straw, only to get eaten when the wolf blows it down with ease. The same thing happens to pig number two, who tries to do better but doesnât make a sufficient commitment, building a house of sticks. Only pig number three  escapes because she had enough foresight to build her house of bricks. Pig number three would have survived not only the wolf but a hurricane or a fire or a blizzard. The brick house symbolizes a sound public health and social service infrastructure.

Unfortunately it is a superficial if seductive analogy.  One of the reasons I have not responded to your insistent and well founded requests over the years to spell out what I mean by rebuilding the public health infrastructure is that every time I sit down to do it I run into unexpected difficulties. It turns out not to be as simple as waving a nursery rhyme under the noses of policy makers.

Consider, for example, the meaning of the word "infrastructure." There is a halo effect from the use of this word for bridges and roads and electrical grids but when applied to public health it doesn't transfer easily. Infrastructure is the "structure" that is below our vision, the stuff we take for granted, donât know is there or donât understand  but that nevertheless makes many other things possible by supporting them. Infrastructure doesnât produce anything but is part of societyâs capital. This seems straightforward, but isnât. If you try to stipulate what part of the public health or social service or any other system is infrastructure not everyone can agree. Bank of America is not infrastructure but the banking system is part of the economyâs infrastructure. A state public health laboratory is not part of the public health infrastructure but most of us consider the laboratory system to be an essential element of infrastructure. Similarly for our disease surveillance system, which provides us with the "situational awareness" we need to make decisions about disease outbreaks or resource allocation. It's public health infrastructure. But being infrastructure doesn't automatically make it good. There are things that are infrastructure but have no particular public purpose or that facilitate some private one (the wave of armory building in the wake of the 1877 railroad strikes is a historical case in point but there are many others).

Then there are things of ambiguous status. What about the vaccine production system? A no-brainer youâd say? I had a long discussion about this with a like-minded colleague over the lunch table but we couldnât agree. He is an economist who doesnât consider the vaccine system to be part of infrastructure, whereas I argued it was. I'm less sure about the nation's drug manufacturing capacity.

So, is it possible to agree on what public health infrastructure is? And if we agree, and agree that the government needs to strengthen it, will the public health community be able to organize itself to demand that change?