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

In this series of editorials, we have often commented on the importance of identifying the course of action that may have the most impact. To that end, we have frequently focused on the factors that are ubiquitous and where, therefore, action may influence the health of many. We have not, however, written much about where we should act. Public health has a responsibility to act at local, national, and global levels. Although that may seem, at first glance, self-evident, it raises the perennial challenge of trying to do everything for everyone, hence achieving very little indeed. Therefore, we focus on action at one particular level—the local level.

ALL PUBLIC HEALTH IS LOCAL

Our comments are grounded in, and informed by, the excellent editorial of Bishai et al. in this month’s AJPH.¹ Bishai et al. argue that public health should act locally for three reasons: first, because local public health policies have the potential for high return; second, because local action is better positioned to address gaps between health haves and health have-nots; and third, because local public health action stands as a bulwark of ongoing progress and action even as national policies slip into “gridlock and regime dysfunction.”^1(p673)

Bishai et al. are careful to note that local action need not happen at the expense of national (and we would argue, global) action, and they observe that some actions simply need to be local in scale to be effective (e.g., epidemic control, regulation of nationally available resources and products). They suggest, however, that local action is paramount to the goals of public health because “public health policies that matter most are the ones that affect things that people have the most contact with.”^1(p673)

We agree with the assessment of Bishai et al. and their acknowledgments that public health needs to act at multiple levels and that at the end of complex causal chains, all health impact is local and suggests the importance of local action.¹ Several other articles in this issue of AJPH make these points elegantly, informing our thinking about this issue further; we highlight three.

LOCAL ACTION INFLUENCES POPULATION HEALTH

First, Sadler et al.² tackle the unfortunate events in Flint, Michigan, which hit the national press more than a year ago after it became clear that lead in the pipes, arising directly from many years of infrastructural neglect and callous political decision-making, had rendered Flint water nonpotable. Sadler et al. show that blood lead levels were highest in areas where houses were oldest and where housing conditions were the worst. These are indeed very local conditions.

There is abundant evidence for a link between qualities of the built environment and health,³ and the data of Sadler et al. add to this body of evidence. Seen through the lens of this commentary, however, these data also do a great job of showing the importance of the local. The core foundations of the Flint water crisis were historical and political, with decisions at the state level shaping the conditions that created the problem.⁴ Nevertheless, local conditions—namely, poverty and housing neglect—have contributed to the problem, differentially heightening exposure to the problem for the more vulnerable residents of the local Flint community.

Second, Eastment et al.⁵ present data demonstrating that approximately 3% of all HIV- diagnosed persons and 7% of virally nonsuppressed persons living with HIV/AIDS in King County, Washington were incarcerated in 2014. Upon incarceration only 49% of this group was virally suppressed, but, impressively, within a year of release, 62% of this group were, approaching the 79% prevalence of viral suppression among the general HIV-positive population in King County.

The authors correctly conclude that persons living with HIV/AIDS who are arrested are disproportionately nonvirally suppressed but also that incarceration presents an important opportunity for reengagement with HIV care. This, again, is a terrific illustration of the importance of local conditions and the power of local action to improve population health. It is not at all surprising that marginalized populations, who are less likely to be linked to care, are more likely to engage in dangerous occupations and activities that bring them to the attention of the legal system. It is, then, to the credit of the local incarceration system that this encounter with the law becomes an opportunity for engagement with HIV care, leading to viral suppression and improved health.

In some respects, national and state-level policy that prioritizes the availability of HIV-treatment through systems of incarceration is a necessary, but clearly insufficient step. Local action and an effective and well-functioning incarceration system in King County is needed to ensure that incarceration is indeed exploited as an opportunity for treatment linkage toward better health.

Third, Shacham et al.⁶ evaluate the risk of Zika transmission using a marker of sexual activity and the demographic distribution of the Aedes aegypti mosquito. They show that 507 counties across the United States have the highest risk of Zika virus exposure among the 3018 counties in the contiguous United States. Shacham et al. build on the discussion, making a different, but complementary point. Namely, public health priorities vary across local areas, and there can be substantial heterogeneity in local needs and, appropriately enough, interests.

Bishai et al. make an argument for “authentic community priority setting,” and this seems to be an occasion when national modeling efforts indeed provide an opportunity for clarity about what may threaten a community that can then guide such local priority setting.¹

INFORMING LOCAL ACTION AND POPULATION HEALTH

Although in this editorial we have focused on local action to improve the health of the public, we do not see such action as separate from the scholarship that is AJPH’s stock-in-trade; the two are linked, and the research of consequence we advocate should inform local action. The call to thinking about what affects population health can inform research as much as it does action. In the former we frequently worry about the generalizability of our findings, so this is not a call for hyper–local inquiry that has applicability only to a narrow jurisdiction. Rather, this suggests that scholarship can productively keep in mind that its applicability is frequently local and that our work needs to produce generalizable knowledge and inform local action. That makes the work of public health research more challenging, indeed, but perhaps more interesting and closer to generating scholarship of consequence.