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

In our comment on the July issue of AJPH, we focused on the following question: why do we do what we do? We suggested that the role of public health is to maintain a relentless focus on the health of populations, on the causes of morbidity and mortality, and on persistent intergroup differences that challenge population health.¹ Today, informed by an excellent accompanying editorial by Buekens,² we ask an ancillary question: what does it take to do what we do?

The health of populations clearly depends on the hard work of those whose primary responsibility is indeed safeguarding public health. It depends as well, however, on the engagement of others, across all sectors, whose work also influences the health of populations. It depends on the work of those whose primary responsibility is ensuring the availability of educational opportunities that can pave the way for health across the life course, those who are responsible for ensuring transportation options that reduce air pollution and needless accidental injury, and those who are responsible for the economic structures that promote, or discourage, economic mobility. What does it take, then, for those of us in public health to engage these other sectors toward a healthier world?

Informed by Buekens, we suggest two answers. First, we need to communicate clearly and consistently the importance of health as a consideration in all decisions made by these other sectors that produce health. Second, it falls on us to maintain this focus on health even when the voices around us conspire to marginalize the health of populations.

ON COMMUNICATION

Buekens correctly notes that we need to ensure we are telling our story consistently “rather than relying on the numerous public health crises that make us highly visible only on an intermittent basis.”^2(p1256) We could not agree more. But what does it take to communicate in this way? To our mind, it requires two approaches that are not necessarily comfortably worn by those of us in public health.

First, it requires constant and consistent engagement with promoting our message and a realization of the import of ensuring the social, economic, and political structures that improve the health of populations. In some ways such engagement may seem “self-promoting,” and undoubtedly at some level it is. We argue, however, that such engagement is nondiscretionary. If organized public health could achieve its ends without the involvement of other sectors, then perhaps we could simply put our head down and do our own work. But the production of health requires, as noted, the engagement of nonhealth sectors. There is simply no way to ensure that those whose primary focus is education, transportation, housing, or economics will continue to elevate health as a concern in their thinking and decision-making without our communication that health should, in fact, be central to all of our decisions. And who, but us, has the responsibility to continue making that case, consistently and clearly?

Second, it requires this communication even more in times when the message of public health is not a dominant thread in the public narrative. This indeed may be such a time. And it falls, again, to us to note that efforts to dismantle established legislation providing health coverage for marginalized groups represent a step backward, that regressive taxation that will widen income gaps is inconsistent with our goal to create a healthier world, and that disinvestment in affordable housing claws back hard-won gains in the area, threatening the health of the public.

ON COURAGE

This leads well to the second point made by Buekens: the importance of doing our work without fear of consequences. This is a powerful reminder of the potential challenges that we may face and that we have a responsibility to overcome. Think of the importance that courage, without fear of consequence, played in bringing about the successes that public health has achieved in the area of HIV/AIDS, moving a disease that was once a rapid death sentence to a chronic disease.

In the early 1980s, HIV/AIDS was a harsh physical reality for many communities. And that reality was compounded by an enormous stigma that was affixed to the disease, with many viewing HIV as a “punishment for immorality.”³ The stigma that was carried by men who have sex with men and particular minority communities contributed to widespread fear, delaying our acceptance of this disease as a public health concern by more than a decade. In the face of government inaction, it fell to advocates to remind us that it would require a concerted effort to address the HIV/AIDS epidemic. Groups such as the Gay Men’s Health Crisis and the AIDS Coalition to Unleash Power were instrumental in pushing government and regulatory agencies to recognize the scope of the epidemic,⁴ paving the way for prominent individuals to tell the story of those with HIV/AIDS and bringing the experience of the disease to the wider world.

These efforts contributed to the social momentum that buoyed us toward effective treatments that have transformed the progression of the disease, as well as to reductions in stigma and creation of conditions for ever-better HIV prevention. This in turn has led to a point at which we can realistically hope to see the elimination of the disease in the coming decades.

But this progress, seen only as a series of successes, hides in the recesses of memory how difficult it was in the early 1980s for advocates, patients, and those in public health to push back on the dominant narrative of exclusion and fear, to tell the story of those with HIV, and to nudge recalcitrant local and national structures toward an embrace of the problem and toward investment of systems into resources that eventually led to the solutions that have transformed the face of the epidemic. The victories achieved by the HIV/AIDS movement, even as they remain incomplete in the face of a disease that continues to infect millions around the world, serve as a powerful reminder that action in the face of deep social resistance is sometimes the responsibility of public health.

ON A GLOBAL LENS

Buekens also notes the importance of engagement with a global lens, of public health’s involvement with the challenges that face an interconnected world. Our population health lens is heavily weighted toward high-income countries where much of the field of organized public health has arisen and still rests. Buekens reminds us that a public health of consequences has a responsibility to remember where the problems reside and that billions of people worldwide face frequently neglected challenges requiring a relentless focus on our part over the coming decades.

At its core, the Buekens piece pushes us to ask a pair of questions. First, how do we maintain our focus, in the face of opposition and sometimes apathy, on the ambition of improved population health? Second, how do we best ensure that the health of populations stays at the center of what we do as societies, worldwide? These are not easy questions; answering them requires a public health without fear of consequences indeed.