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

Public health rests on the creation of social, economic, and political structures that promote health. A healthier world requires a stable investment in health systems, regulation to preserve environmental sustainability, quality schooling to create health across the life course, livable wages, and affordable housing for all. There are data on the relation between each of these factors and healthier populations, and, conversely, disinvestment in these factors threatens the health of the public. A public health of consequence requires, to some extent, an engagement in these issues, both in the generation of scholarship to illuminate how best we may achieve the foundational structures that promote health, and in actions taken in partnership with other sectors, both public and private, to get us there. Creating the conditions that make people healthy frequently requires policies, often themselves a result of legislative action. This makes politics and the processes of policy formation at the municipal, state, and federal level itself of interest to public health, suggesting, in a paraphrase of Rudolf Virchow, that public health is politics on a grand scale.

PUBLIC OPINION

A core question of import, therefore, is the nature of politics itself and what can shape political decisions, with an eye—given our particular concern—toward creating the conditions that produce health. Although there are easy arguments to be made for the role of factors such as history, demographics, and special interest influence in political decision-making, it is equally clear that broad public opinion and social norms are key drivers of political decisions, particularly in representative democracies. Politicians must account for legislative action to their voters and are, therefore, reasonably enough, apt to be concerned with voter positions on issues, and to be guided, at least in part, by an awareness of voter anger or approval of their actions. At a deeper level, values inform political actions and provide the moral underpinning for a range of political decisions. Values, in turn, are determined by a broader public conversation that is generated by key stakeholders and broad-based public engagement. Values, expectations, and social norms therefore lead to policy action and, together with such action, form the basis on which many of the foundations that shape population health are built.¹

This then makes the shaping of public opinion an important concern of public health, one that has preoccupied both the scholarship and practice of public health over the years, around a range of issues.² Two articles in this issue of AJPH make an important contribution to the question of whether we can, and how we may try to, change social norms and behaviors.

Carrying Firearms in Public Places

First, Wolfson et al. consider the question of US public opinion about carrying firearms in public places. It is hard to think of a contemporaneous issue that is more controversial and politically charged than the issue of firearms.³ Although nearly 100 000 people are directly affected (i.e., injured or killed) by firearms every year in the United States, at a per-capita rate far higher than our peer nations, we have some of the least restrictive firearm policies of any comparable country. Public health scholarship and action on this issue has far lagged behind the extent of the problem, although recent action by public health in the area may hold promise.⁴

What makes the issue particularly challenging are deeply held and felt beliefs on both sides of the issue, insofar as there are sides to a complex concern. Generally, gun rights advocates contend that gun ownership is a fundamental constitutionally guaranteed right in the United States, precluding any form of effort to maximize gun safety. An approach informed by the evidence would suggest that efforts to limit some forms of gun ownership and to promote gun safety can save lives and minimize injury. A flashpoint in this discussion has been so-called open carry, the right to carry guns openly in public places. Wolfson et al. assessed public opinion and found that most Americans, including most gun owners, support restricting public places legal gun owners can carry firearms. These views contrast sharply with the current trend in state legislatures that is moving to expand where, how, and by whom guns can be carried in public.

The authors suggest that recent state laws and proposed federal legislation that would force states to honor out-of-state concealed carry permits are out of step with American public opinion. This presents important data to inform a raging public discussion. Data such as those provided in this article can, and should, be a part of the public debate, bringing to a fore the other forces that may be shaping legislative decisions—centrally, in this case, industry pressure. It is probably infeasible to expect high-quality data to be available on all issues of public moment, but Wolfson et al. provide a good case study of how such data can inform an issue of contemporary concern, potentially toward influencing policy decisions that can create a healthier world.

Sugar-Sweetened Beverages

Second, Farley et al. evaluated a mass media campaign to reduce consumption of sugar-sweetened beverages (SSBs) by disseminating messages emphasizing the health risks of SSBs through television, digital channels, and local organizations over 15 weeks in a rural area.⁵ This issue is particularly salient given the dramatic increase in obesity in the United States over the past three decades, and the role that SSBs play in overall calorie consumption among Americans.⁶ Farley et al. conclude that the brief media campaign on SSBs was followed by intended changes in beliefs and consumption and suggest that additional media campaigns on SSBs should be attempted and evaluated.

NORMS AND OPINIONS

These two papers together then surface the importance of norms and opinions as foundational drivers of health. We see relatively few articles in AJPH or other journals about these issues. This is understandable given that they are hard to assess and harder to change. This work may become ever more important during a time of particularly rancorous political discourse that may be injurious to the health of the public. It will be norms and opinions that will facilitate, or mitigate, the consequences of many of the actions being proposed by the current administration, suggesting that public health’s understanding and efforts toward changing norms and opinions may matter now more than ever.