Can Population Health Science Counter In-Kind Dangerous Oversimplifications? A Public Health of Consequence, October 2017

We are living in an era of triumphant compelling simplification. It is not too far a stretch to suggest that the federal election that brought President Donald J. Trump to power rested on large swaths of the population believing the statements made by candidate Trump that were oversimplifications of complicated truths. Candidate Trump suggested that building a wall would limit immigration from Mexico, eliding sober assessments that, historically, walls have rarely been a good long-term solution, that such a wall would make very little difference on immigration, and that over the past few years, there have been more Mexicans leaving the United States than coming to the United States.¹ And yet, Trump built a successful presidential campaign by constructing a compelling notion that a wall would be a solution to a nonproblem.

Trump’s victory has been attributed, in part, to his mastery of new digital communication media, particularly Twitter, in much the same way that previous candidates won by mastering the medium of their time, most notably President John F. Kennedy with television. Of course, the characterizing feature of new digital networks is that they thrive on concision, compelling users to distill messages into brief expository bursts. This makes it easy to say “build a wall” over and over again, and much harder for those who try to bring nuance and shading to a complex discussion to do so with the same speed or penetrance for an equivalent broad segment of the population.

POPULATION HEALTH IS COMPLEX

This brings us to simplification in the context of our understanding of population health, and the role of science to bring clarity—even if complex and nuanced clarity—to areas that can be harmed by dangerous oversimplification. Unfortunately, the production of the health of populations is complex.² Historical factors influence health intergenerationally, and forces across time and place, ranging from the behavioral to the social, economic, and political circumstances that shape our daily lives, all generate health of populations. Increasingly, we are coming to realize that efforts to isolate causes are encumbered by the ineluctable role of other factors, and that our thinking might more generatively move to an understanding of causal architectures,³ giving us a full picture of complex causal patterns that shape health. That creates a picture of health production that is ill-suited to expository 140-character summaries.

This presents population health science with a dilemma. The news cycle and broader decisions informed by the dominant public conversation are shaped, inexorably, by compellingly conveyed simplifications that capture the public imagination. But, conversely, our engagement with a topic that is genuinely complex limits our capacity to counter with compelling simplifications in kind, threatening to relegate the concerns of population health to the back burner of the public conversation.

How does public health then deal with this challenge? How do we overcome the problem of oversimplification, while continuing to press for recognition and visibility of the compelling public health issues of our time? We suggest three approaches in the science that can be helpful, each illustrated by an article in this issue of AJPH.

ILLUMINATING POTENTIAL SOLUTIONS

First, and centrally, we have a core responsibility to produce science that cuts through the noise, that sheds light on the production of population health around issues of contemporary concern in ways that are useful and can illuminate potential solutions. We suggest that this can be done, even as we recognize and embrace complexity, and that it remains the central responsibility of population health scientists. The article by Nestadt et al. in this issue of AJPH does just this (p. 1548). Using data about suicides in Maryland, the authors show that higher suicide rates in rural counties were driven by male firearm suicides specifically, and that there was no urban–rural difference in nonfirearm suicide. This is an important observation around a topic that is politically charged, and should be of central interest for public health.⁴ It provides nuance that can cut through the oft-repeated public statement that, absent firearms, people will find other ways of harming themselves and others. It turns out, as this article suggests, that that may not be the case, providing more data that should inform a rational public discussion about ways to mitigate the consequences of firearms in the United States.

SCIENCE IS A METAPHOR

Second, all science is a metaphor, providing us lenses through which we can see and understand the world better. That understanding stands, in turn, to help us clarify what matters, or what should matter, nudging the broader public conversation toward action. Taksler and Rothberg used Vital Statistics mortality data to assess years of life lost to each cause of death in the United States and compared it to the number of deaths (p. 1653). In doing so they show, for example, that accidents, suicides, and homicides each caused twice the share of life-years lost as share of deaths, resulting in a reordering of burden of disease tables if we consider years of life lost instead of number of deaths. This offers an important perspective, one that challenges our typical view of burden of population health and should enter into any consideration of resource allocation, both financial and our own energy and attention given to the issues that challenge the health of populations. Analyses such as the one by Taksler and Rothberg provide us with a different perspective, forcing us to interrogate received wisdom, and hopefully allowing us to more thoughtfully set research and action agendas.

DOCUMENTING COMPLEXITY

Third, science has a responsibility to bear witness, to provide the documentation to the complexity of population health challenges, even if they fall out of the dominant public din. Returning to the topic with which we started this comment, the issue of immigration from Mexico, Cheney et al. conducted a qualitative study to document premigration experiences of violence and postmigration health status in male-to-female transgender individuals from Mexico (p. 1646). They show that these asylum seekers suffered assault and abuse with, not unexpected, real psychological consequences throughout their lives. This makes a powerful argument for the burden of disadvantage that sometimes drives migration and that is the unspoken story behind the issue that has been, in public discussion, reduced to its absurd oversimplification.

A BULWARK AGAINST DANGEROUS OVERSIMPLIFICATION

In sum, we see science as a bulwark against the dangerous oversimplification that has colored much of the public discussion in recent months. However, to meet this charge we need to produce science that is relevant to contemporary concerns, that challenges accepted frames of reference, and that documents the causes of poor health even if away from the glare of the dominant debate. The articles in this issue of AJPH that do so serve this cause well.