As a student of systems science, I understand that the major public health problems of the twenty-first century are dynamic, complex, and interconnected. I owe this insight to an expanding constellation of thought leaders, modelers, and scientists across disciplines and sectors. Indeed, Donella Meadows provided the inspiration for the Journal theme this month, Integrating Public Health Across Sectors, through her profound yet accessible book, Thinking in Systems: A Primer (White River Junction, VT: Chelsea Green Publishing; 2008) which is manifest in myriad ways through the assembled collection of papers herein. For instance, it is instructive to view the Health Trust System proposed by Chernichovsky and Leibowitz (p205) to reconnect public and population health to personal medical care in the United States through a systems science lens. Their approach is a constructive, positive alternative to an inefficient, costly system that fails to provide medical care to increasing numbers of people or invest in societal solutions that promote public and population health for the long term.
As a community-based public health researcher, I have witnessed firsthand the unmet needs of study participants, and value the question posed by Merritt et al. (p211): To what extent do researchers have an ethical responsibility to provide ancillary care, i.e., health care beyond what is necessary to ensure scientific validity and do no harm? The experiences of their research team in the Nepal Newborn Washing Study provide an on-the-ground account of the living conditions and unmet needs of their study participants, including a lack of nutrition, clean water, sanitation, and basic preventive and therapeutic health services. While invoking the elementary moral principle of the duty to rescue, they call for further conceptual and empirical work to identify and avoid possible adverse consequences of a more explicit, systematic recognition of ancillary care obligations, such as increased burdens on researchers based in developing countries or disincentives for sponsors to fund research on conditions that afflict the poorest populations.
As a devotee of joint urban planning and public health approaches to health promotion, I have witnessed the emergence of a body of evidence, especially over the past decade, of pathways through which the food environment affects healthy eating. For instance, Farley et al. (p211) found that 41% of 1082 retail stores in 19 US cities that do not primarily sell food nonetheless sold calorie-dense snack food, most often within arm's reach of the cash register queue. Meanwhile, Roberto et al. (p312) demonstrated that calorie labels on restaurant menus affected food choices and intake, and further that adding a recommended daily caloric requirement label increased this effect.
As a citizen of the digital age, I have been humbled by the need for enhanced human connections in our daily lives and applaud the efforts of local governments such as that of Curitiba, Brazil, to facilitate this aim through environmentally friendly public transit and social programs. Whether it is the dramatic sight of hot air balloons at Barigui park (see cover image) or the safe network of bicycle lanes in the town center (p196), Curitiba embodies the effort to integrate public health across sectors. Even where the evidence is lacking, as in the connection between art, healing, and public health explored by Stuckey and Nobel (p254), it makes moral and practical sense to heed the advice of Donella Meadows in her prescient book and expand the horizons of caring.