Practice Is the Purpose of Public Health

All who work in public health share this common goal: to prevent disease and promote health. So universal and so worthy, this goal is claimed by government agencies, research institutes, academic departments, community-based organizations, nonprofit foundations, and health care institutions. And their claims are not empty—all contribute to advancing public health.

But not all will claim the mantle of “public health practitioner.” In this editorial we reflect on the work of public health practitioners and consider how the Journal might more effectively capture and acknowledge their efforts. We are concerned that the published literature—including work published in the Journal—does not adequately document the actual experience of the public health practitioner. We care about this for 2 reasons. First, documentation of practice experiences should contribute to the evidence we draw upon to plan our activities. Second, public health practitioners form the majority of public health workers, and these pages should reflect their endeavors.

WHO IS THE PUBLIC HEALTH PRACTITIONER?

Who is the public health practitioner? The public health practitioner is the person who conducts the daily work of public health on the front lines of federal, state, and local health departments. Defining the daily work of public health is not an easy task, because it is so varied. A police department enforces the law. A parks department oversees the parks. Both evoke clear images of practical work that matches their missions. But “doing public health” is less clear. The New York City Department of Health and Mental Hygiene, among others, tries to present a complete picture of its work by listing its activities from A to Z.1

What does public health practice comprise? Birth certificates are issued, day care facilities are certified, mosquitoes are sprayed, pests are controlled, restaurants are inspected, people with sexually transmitted diseases are treated, and so on. Each day across the United States, from birth to death, at work, school, and play, the lives of people are touched by the labor of public health practitioners. And through their activities, these practitioners make our lives healthier and safer.

Such an expansive catalogue of activities ought to be seen as exciting as well as important. Yet government health departments are often characterized as lacking vision, as being limited in innovation and having insufficient passion to rally commitment to public health. The drabness associated with bureaucracy and conformity color both professional and public views of health departments. Rather than the head and hands that guide the public health agenda, the public health practitioner is seen as the hands alone. In this view practitioners do little to define public health priorities. Their activities follow mandates, as laid down by laws, codes, and regulations. Work is directed by the legislature, not by the data. While acknowledging the importance of daily public health work, those who pursue the goal of improving public health in university, research, and community settings often equate public health practice with drudgery.2,3

WHO CONDUCTS THE CORE FUNCTIONS OF PUBLIC HEALTH?

Health departments endure perennial budgetary and administrative constraints. Programs are underfunded; staffs are underpaid. But tight budgets and recruiting challenges are only part of the problem. Also at issue is whether the entire range of what are often called “essential” or “core” public health services appropriately reside in health departments.4 Broadly, these activities can be grouped under the headings “assessment,” “policy development,” and “assurance.” The activity list generally includes 10 major subheadings: (1) monitor health status, (2) investigate health hazards, (3) inform and educate the public, (4) mobilize community partnerships, (5) develop policies to support health goals, (6) enforce laws and regulations, (7) ensure a competent, skilled health workforce, (8) provide links to health services, (9) evaluate programs, and (10) conduct research.

Taxpayers’ dollars support all these activities, but often it is not state and local health departments that oversee, conduct, and coordinate them. Health departments do not have the funds or the capacity to attend to all the functions deemed “essential.” Surveillance, outbreak investigations, some clinic services (such as treatment of sexually transmitted diseases and tuberculosis), and enforcement of public health laws and regulations stand out as the functional “essential services” of today’s public health practice. These services, which may be required by law, have withstood budget reductions, but other activities on the list have lost out. For too many health departments, limited capacity and resources in areas such as policy development, community mobilization, program evaluation, and research hamper the pioneering spirit of public health practice. The roots of drudgery are grounded in the failure to secure and fund a publicly coordinated agenda for essential public health functions, whether or not it is health departments that carry these out.

These challenges notwithstanding, the transformation of health departments in the past 75 years has been monumental. When public health departments were established, control of communicable diseases and environmental sanitation dominated their activities. The public health legislation that guides health departments today has its origins in that era. The pioneers of public health practice spoke out vigorously about the squalid conditions that threatened all residents and advocated policies and programs to address these conditions. As the leading causes of death shifted to cardiovascular diseases and cancer, public health practitioners pointed to the need for research to identify effective intervention strategies. What followed was a shift from practice to research. Epidemiological studies verified the importance to individuals of quitting smoking and maintaining a healthy weight. Randomized clinical trials demonstrated that lowering blood pressure and blood cholesterol could reduce premature mortality.

WHY ISN’T MORE RESEARCH TRANSLATED INTO PRACTICE?

Health departments have taken up the challenge of translating more research into action. Legislation that limits exposure to secondhand smoke has been vigorously promoted and backed by the authority of health departments. Today, the evidence of a tidal wave of obesity is prompting health departments to speak out again. In the words of Hermann Biggs, general medical officer for health for New York City in 1911, “These conditions and consequently the diseases which spring from them can be removed by better social organization. No duty of society, acting through its governmental agencies, is paramount to the obligation to attack the removable causes of diseases.”5

In many cases, what to do is not at issue; rather, the question is how to translate research into practice. Here the distinction between academic public health institutions and government health departments has become blurred. Academic institutions undertake efforts to test various strategies to deliver proven interventions. Health departments seek to implement research findings and evaluate their effectiveness. Intervention research shares many of the characteristics of serviceoriented programs. A key distinction is that an academic project rarely becomes institutionalized in academic settings. The success of a program in an academic setting is measured by successful implementation, careful analysis, and publication of findings. The sustaining of programs is left to health departments, where success is measured by improved health outcomes.

HOW CAN MORE PUBLIC HEALTH PRACTICE WISDOM BE PUBLISHED?

Researchers turn to practitioners to convert their interventions into ongoing services. But the published record documents little of the practical experience of program building. Information conceived only as numbers denies the rightful place of wisdom and experience in the published record. The knowledge base needs to include shared experiences and observations about making programs work. Such relevant information needs to be based in theoretical concepts and on real-life models, and it needs to be written so that other practitioners and community partners will be able to understand it without advanced training.6

It is the intervention efforts of academia that most often find their way into print and thereby into the public record of practice. While it is often health departments that are tasked to convert a research-based intervention program into a sustainable service, little is ever recorded of how this is done. Like academics, health departments record numbers but are far less likely to record programmatic experiences. This is a great loss, for few ideas are entirely new; many are “old wine in new bottles” and often past experience is relevant to contemporary innovation. The institutional memory of a health department often resides in its long-serving employees, a risky archive given the growing mobility of the workforce.

Best practices contribute to understanding what works in public health. Wisdom gained through reflection on experience (what worked, what didn’t, and why) is not the same as anecdote. Simply documenting “best practice” may not capture what practitioners thought would work, on the basis of theory and experience, but failed in practice. It is as important to future programs to describe what did not work as to describe what did work. To change disease patterns, we need sustained interventions that are delivered in real time, that is, after the research is over. The voice from the field is essential.

Our intent is to encourage public health practitioners to speak out on compelling issues and to submit papers about their programs, projects, and processes to the Journal. While we celebrate the work of practitioners, we also want to ensure that their wisdom becomes part of the public health record. And so, the members of the Journal’s editorial board and editorial team invite you to join us at a special session of the American Public Health Association’s Annual Meeting, “Promoting Public Health Practice in the Journal,” on Monday, November 17, at 10:30 am (session 3097, MCC room 302). Together, we aim to translate the ideas presented in this editorial into action.