A Public Health of Consequence: Review of the April 2017 Issue of AJPH

It is not unusual to read calls for multisectoral engagement to effectively promote population health. In many ways, the suggestion is inarguable: the work of improving population health rests on the shoulders of a broad range of sectors, including the public sector, the private sector, and civil society. It is less common, however, to see examples in proximity that highlight just how work by different sectors can stand to advance, or get in the way of, the improvement of population health, as we see in this issue of AJPH.

PRIVATE SECTOR INFLUENCE

Polinski et al. assess CVS Health’s well-publicized move to discontinue tobacco sales in all of their pharmacy locations.¹ This article shows that after CVS’s tobacco removal, household- and population-level cigarette purchasing declined significantly. In many respects, there is nothing surprising about this analysis and these findings. There is ample evidence that ready point-of-sale availability of health-harming products, including tobacco and alcohol, is associated with greater consumption of these products, particularly among populations that are close to points of sale. Therefore, the CVS study is elegant experimental affirmation of the observational data and confirms that reducing the ready availability of tobacco stands to reduce use, pointing the way to approaches that can minimize smoking in populations. This provides a good illustration of private sector action that can improve population health.

PUBLIC SECTOR INFLUENCE

The articles by Burgette et al.² and Fenelon et al.³ illustrate how public sector efforts can contribute to better population health. Burgette et al. look at enrollment in Early Head Start and dental service utilization, including preventive service utilization among children. They show that Early Head Start enrollees have a mean of 30% more dental visits than do children who were not enrolled in Early Head Start. This study adds to the body of work showing the importance of early childhood programs to improve health. It is a particularly timely demonstration of the importance of programs such as Early Head Start during a time of transition in the US federal government, when public policy investments in programs such as Early Head Start may well be revisited and reconsidered.

Fenelon et al. examined whether access to housing assistance is associated with better health among low-income adults. They found that housing assistance was associated with improved health and psychological well-being for individuals entering public housing and multifamily housing programs. This reinforces the notion that housing support needs to be a cornerstone of service provision to promote health among disadvantaged populations; this is also an important message at a time when the US Department of Housing and Urban Development is reconsidering its priorities in the new administration.

IN NO SMALL PART POLITICAL

Population health is, definitionally, a complex product of influences that include the physical and social environments, individual behaviors, and biological and genetic factors.⁴ It therefore stands to reason that no single sector shapes all these environments, that no one approach to improving population health will succeed in isolation. This makes it the inescapable role of public health—if it is to seriously tackle the improvement of population health—to engage with the social, economic, political, and cultural forces that influence our collective health. If private sector efforts influence population health, they must represent part of the remit of public health. And if political changes threaten successful public programs, public health has to see its role as being, in no small part, political. It seems to us, therefore, that articles such as these in this issue of AJPH are an important reminder of the role of a range of sectors and that to succeed public health must embrace its responsibility to engage with all these sectors, as needed, toward our ends.

This has implications both for the work we do and, critically, for how we teach our students. It urges us to move well beyond teaching our students the core methods of surveillance and multivariable modeling (although both of those remain important). We must make sure that we prepare the next generation for engagement with the range of sectors that create the environment that generates healthy populations. That would be a worthwhile investment in our collective health for decades to come.