We want to thank our editorial colleagues at the Journal for the opportunity to reflect on our experiences in public health, particularly because one of us is nearing the end of his career and the other is just beginning hers. As a result of working together for nearly a decade, we have had a number of conversations about the nature of public health, public health practice, and the values that drive us in our profession and professional lives.
One recurring conversation is about the ways in which public health is framed and how this framing affects how public health problems are defined and addressed. As noted by Sylvia Tesh in her influential text, Hidden Arguments: Political Ideology and Disease Prevention Policy (New Brunswick, NJ: Rutgers University Press; 1988), the framing and definition of health problems drives the critical debate regarding not only who is responsible for creating these problems but also who is responsible for devising the solutions.
A significant, widely used framework during the early nineteenth century was the theory of miasma, which posited that disease was caused by foul-smelling physical environments. Although subsequently eclipsed, miasma was the basis of much of the early understanding of public health. It provided an intervention focus directed toward cleaning up the physical environment and an emphasis on social justice through reasoning that political and collective action could clean up the environment and create the conditions under which everyone could be healthy.
By the late 1800s, the germ theory had been widely adopted. This framework was based on the belief that infectious diseases were caused by microscopic organisms and gave rise to what we know as modern medicine. Combined with the emerging industrial revolution and growing beliefs in the benefits of science and technology, attention was directed to the application of technology to address individual and public health problems. This emphasis on technology was reinforced in public health in the early 1900s by a number of foundations, including the Rockefeller Foundation, which influenced the development of the first school of public health (for further reading, see Fee E. Disease and Discovery: A History of the Johns Hopkins School of Hygiene and Public Health, 1916–1939. Baltimore, MD: The Johns Hopkins University Press; 1987).
Recently, public health has come full circle, returning to a focus on creating healthy environments and ensuring social justice. In this issue of the Journal, Freedman et al. report that neighborhood characteristics and economic disadvantage significantly influence morbidity from chronic diseases as people age (p. 79). Recognition of the structural and social factors that influence the production and distribution of health reinforces the emphasis on social justice. Models that have emerged with this perspective include the political economy of health, social medicine, social determinants of health, and structural determinants of health, to name just a few. While differing in important characteristics, all of these frameworks focus on the broader social context: social structures and systems that allocate and determine the distribution of health and illness in society.
Over the course of the past century, public health has increasingly been viewed as a government-sponsored activity. This perspective poses difficulties in attempts to effect the broad social changes that are called for given a focus on social determinants. The paradox may be resolved by instead highlighting the collective nature of public health. That is, in addition to formal, publicly funded public health, there is the important role of broader community engagement in health improvement efforts. It is through viewing public health in this collective sense that we are optimistic about our ability to improve health through social change. We look forward to continuing this dialogue about public health frameworks, the values that are embedded in our actions, and the importance of social justice.