50 Years Ago
Public Health and the Law
As we look at our world it is not surprising that many feel they cannot understand what is going on about them and what it all means for them professionally and privately. Surely it is no wonder that our time is characterized by pervasive feelings of insecurity, and a sense that we have been cast adrift without compass or charts. . . . This mood is evidently the result of the break-up of a long-established social order and the consequent dissolution of an accepted structure of value and belief. In such circumstances it is essential to have guidance and interpretation, especially in areas where changes are occurring and where their implications are obscure.
From AJPH, May 1968, p. 817
Health in Model Cities?
The first basic point is that health does not occur in isolation, and therefore that attention to health alone is not enough. . . . [H]ealth problems must be considered as the consequences of human ecological systems operating in man-made environments. Ecologic thought has always been a significant strand in the fabric of public health theory, but with rapidly developing specialization it is essential that all types of workers entering the urban arena learn to think in ecologic terms. Leadership must be interdisciplinary, including an orientation to health.
From AJPH, May 1968, p. 818
My younger brother David took his own life recently. Facing health problems and bleak job prospects, he died a “death of despair”—a phenomenon identified by Case and Deaton in their widely cited 2015 study documenting the dramatic rise in mortality rates among Americans who, like David, are middle-aged, White, and have limited education. At his funeral, one friend left early to attend a service for someone else who also had committed suicide; another commented that my brother’s was his fifth suicide-related funeral in recent years. In communities like my Wisconsin hometown, people are being left behind in a changing economy, and they are dying.
I need to feel that I am doing something to address the problems that contributed to David’s death, and volunteering in our county jail feels right. There, I see despair among the incarcerated men and women. We talk, sometimes just about the foods they miss, sometimes about their plans for when they get out. Some find their way back to a productive life, but often they fail to thrive in a world with inadequate social support, minimum-wage jobs, and the demons of addiction and mental illness. Just like in my hometown, people feel overwhelmed by problems that seem to keep getting worse.
In the context of these challenges, many academic investigators struggle with a research enterprise that falls short in creating change for people in despair. Acquiring funding, conducting studies, publishing, and translating findings into meaningful impacts seem to take longer than ever. Too often junior investigators start out with enthusiasm, only to see their ideas die a slow death through endless peer review and suffocating regulatory oversight. Promotion criteria push investigators into increasingly narrow areas, leaving untouched the systemic issues that generate despair. The problems people face are VAST—rooted in Violence, Addiction, Social isolation, and Traumatic life events—but our solutions are often paltry by comparison.
So, what can we in public health do to address VAST needs?
We need to recognize what we are up against. VAST needs affect lives as a syndrome of interrelated causes and effects, and short-term solutions are unlikely to produce lasting change. Problems such as substance use, obesity, and chronic pain happen in the context of one’s overall lived experience. Although we cannot always change that reality, our proposed remedies must at least reflect it.
We also must be willing to drop our professional mantle of clinical objectivity and cultivate “a culture of encounter” in which not only do we serve people with VAST needs but we get to know them too. Spending time as equals with those who have VAST needs, as someone seeking to understand what it means to feel hopeless, broken, and forgotten, has a value that transcends each individual interaction. We need to share a laugh at our human foibles or an opinion about our common experiences—without teaching, judging, or fixing. We need to put aside the education and successes that give us so much satisfaction and share our humanity. It takes time and a willingness to feel off balance or even rejected. But if we are to be agents of change, we must embrace those with VAST needs as our sisters and brothers.
After decades of research, many people still have VAST needs that shape how they live and, for people like my brother David, how they die. As professionals and fellow human beings, we are called to face VAST needs by stepping into the experience of those who despair and finding new ways of applying our talents. As Pope Francis said, it is important “to get to know people, listen, expand the circle of ideas. The world is crisscrossed by roads that come closer together and move apart, but the important thing is that they lead towards the Good.”
Biography
