Public Health, Politics, and the Creation of Meaning: A Public Health of Consequence, July 2019

Our health is the product of the social, economic, and environmental context within which we live. The air we breathe, the water we drink, our education, our friend networks, the places where we live, and the conditions of our work are foundational drivers of our health. This observation, perhaps obvious at this point in time for the readers of AJPH, has one fundamental implication that colors the science of population health and the practice of public health. It suggests, centrally, that the health of populations is inherently political.

It is impossible to separate our social, economic, and environmental conditions from the political decisions and actions that create this context. Decisions that drive quality and availability of housing, for example, inevitably pertain to the allocation of resources and must rest on prioritization of the same through political processes. The conditions of our employment are inextricable from economic circumstance and the motives—including financial—that inform occupational structures, salaries, and opportunities for occupational mobility.

Appreciating that the health of populations is inherently political challenges public health to consider how it can generate the right political conditions that can create health. How may those engaged with the science of population health and the practice of public health grapple with the inexorable entanglement of politics and health? We suggest three approaches that may help us rise to this challenge.

ALIGNING POLITICS AND POPULATION HEALTH

First, we might start with the education of public health practitioners and population health scholars of the future. Public health practitioners typically are trained through an academic public health system that, until recently, was focused on teaching epidemiology, biostatistics, and other canonical public health disciplines and was far less concerned with teaching the practical leadership or advocacy skills needed to engage with and influence political processes. Similarly, population health scientists are trained in these same disciplines to identify causes of the distributions of health in populations; those causes seldom extend to the macro-social and hard-to-assess political processes that are at the foundation of the generation of population health.

There are encouraging signs that this is beginning to change.^1,2 Public health education is moving beyond its traditional disciplinary silos to a more integrative approach to education, one that recognizes that the solutions to complex problems lie at the interstices of disciplines and must draw on eco-social frameworks that start perhaps with the political, moving through levels of influence to include then the behavioral and personal.^3,4 We remain far from having arrived on this front. New accreditation criteria from the Council on Education for Public Health that privilege integration of knowledge across disciplines only came into place in 2016 and the implications of those changes are only now slowly beginning to influence curricula across schools and programs of public health. Population health science continues to emerge as a discipline and, as that proceeds, its remit is slowly coming into focus.⁵ Both these shifts portend well, even as the eventual form of public health education and future scholarship remain to be defined.

Second, it seems to us important that the current practice of public health and the scholarship of population health science embrace the political implications of our work and assertively take on issues of consequence. This is illustrated aptly in an article in this issue of AJPH that considers whether US investments in aid are associated with perception of the United States in recipient countries (Jakubowski et al., p. 1034). Our engagement in public health with issues of health aid investments typically are concerned with either a moral argument—health aid as a means to fulfilling the social justice agenda that is at the heart of public health—or a health outcome argument—health aid as a way of improving the health of global populations. Both these arguments are important and indeed should remain at the heart of public health thinking around our motivation for much of what we do, whether that is around health aid or other matters.

However, health aid does not happen without a political calculus, and Jakubowski et al. provide data that tackle the political implications of health aid in a way that can usefully inform this discussion. We appreciate that there may be some unease in public health about arguments that are nakedly political. After all, if the moral argument is strong and an approach improves health, should it then not be adopted widely? Is the case of public health not made? In a pragmatic world, the political calculus that dictates which resources are deployed, how, and when cannot be ignored, and our playing a role in providing data that can sway that calculus is both worthwhile and a core part of our responsibility.

Third, we will not achieve improved population health without creating a narrative that makes the creation of health in populations meaningful. Political action is motivated by meaning, often by money, and by the implied or explicit significance of a particular outcome. Political actions are beholden to dominant narratives. While the romantic notion of the maverick leader who acts against the tide to achieve what is right has a noble place in stirring fiction, it is largely that: fiction. Political actions represent efforts to implement approaches that are meaningful to the various constituencies represented, be they community members who demand local parks, workers looking for salary equity within the workplace, or citizens demanding clean air in the face of global environmental climate change.

This meaning, however, is created; it is a function of the perspectives we adopt to inform our worldview and the value we attribute to particular states. That suggests that public health practice and population health science must be in the business of creating meaning, informing the political action that generates our health. The article by Jakubowski et al. can be seen to be doing just that—it is generating a narrative around the significance of health aid that gives meaning, informs our motives, and shifts the playing field that informs political action. The creation of meaning may be an unfamiliar role for public health, but one whose import comes into sharp relief when we recognize the inevitability of the political at the heart of what we do.

OUT OF THE PUBLIC HEALTH COMFORT ZONE

In sum, a forward-looking public health, cognizant of its responsibility to tackle the political imperatives that underlie the generation of health in populations, may do well to embed this approach in educating future generations and in our work on a day-to-day basis. Recognizing that we play a role in creating meaning, in generating the narratives that shift political actions, urges us to consider how our science and practice can rise to this responsibility. It is a bolder conception of the work of public health than we may be comfortable with, but is perhaps truer to the core concerns of health than much else with which we engage.