A Public Health of Consequence: Review of the December 2016 Issue of AJPH

A recent effort by the US Department of Health and Human Services (HHS) Office of the Assistant Secretary for Health (OASH) articulated Public Health 3.0 as an effort that emphasize[s] cross-sectoral environmental, policy, and systems-level actions that directly affect the social determinants of health and advance health equity. This approach correctly notes that where we live remains a more important determinant of our health than do our genes, despite substantially more effort in recent years in understanding the latter rather than the former. As described in AJPH a few months ago, Public Health 3.0 represents a next-phase approach in public health, moving beyond the core functions of disease surveillance and environmental approaches to promote healthier communities, to an effort that incorporates health into all aspects of governance, at multiple jurisdictional levels.¹ This approach echoes the “health in all policies” approach that has long been embraced by the American Public Health Association, bringing to this effort the weight of the federal department that ultimately is responsible for promoting the health of Americans. These approaches clearly aspire to tackle the foundational drivers of population health, the ubiquitous factors that we have urged public health scholarship to grapple with, in these pages, over the past year.

SCHOLARSHIP TO INFORM PUBLIC HEALTH ACTION

It seems to us that it falls to public health scholarship to provide the data that can inform Public Health 3.0, or a “health in all policies” approach. Several articles in this issue of AJPH do just that, starting with the essay by Ahern,² who focuses on the utility of population intervention parameters that can help bridge the gap between research findings and policy. This editorial provides a compelling argument for the provision of measures in our work that are readily interpretable for those who are in a position to shift policy. Ahern suggests that such measures “would make a substantial contribution to the effort to translate between research and policy.”^2(pXX) We could not agree more and look forward to more articles in AJPH that adopt this approach. We would see this as entirely consistent with the agenda we are proposing here, one that engages population health scholarship with the conditions that foundationally make people healthy. While a methodological approach may not, at first blush, seem to portend a substantially new focus for public health scholarship, it may well provide a lens through which we present our findings that makes them more relevant, more immediately accessible, and more forward looking as public health transitions to a new era. Four empiric articles in this issue of AJPH contribute data that can also bolster this approach.

CREATING BETTER PLACES

Two articles focus directly on the influence of place on the health of populations. Branas et al.³ wonder if remediation of abandoned buildings and vacant lots can be a cost-beneficial approach to mitigating firearm harms in the United States. Informed by broken windows thinking,⁴ the authors conducted a quasi-experimental study assessing the link between abandoned building remediation and firearm violence, finding a 40% reduction in the latter while finding no change in nonfirearm violence. The authors speculate that blighted structures may create physical opportunities for violence, and ample work in the field suggests that blighted urban neighborhoods may also result in an erosion of collective efficacy, also contributing to more violence.⁴ Importantly, Branas et al. show that taxpayer and societal returns on investment for the prevention of firearm violence were $5 and $79 for every dollar spent on abandoned building remediation. Given the scope of the firearm epidemic in the United States today, this seems indeed like money well spent.

Barber et al. tackle the issue of adverse neighborhood conditions and risk of cardiovascular disease among African Americans.⁵ The authors show that each standard deviation increase in neighborhood disadvantage was associated with a 25% increase in cardiovascular disease risk among African American women, and that risk also increased with increasing levels of neighborhood violence and physical disorder. This work builds on a large body of research that shows the central role that place plays in shaping population health and how the quality of place is likely an inextricable part of the production of health. Both of these studies make a compelling case for the nonignorability of place if we are to improve the health of populations, an argument for Public Health 3.0 that moves us well beyond individual behavioral change to efforts to remediate foundational conditions, toward creating health populations.

IMPROVING COMMUNITIES

Importantly, this call to action to improve place need not be an abstraction. There are growing efforts to improve local communities, informed by health need, and two other articles in this issue of AJPH provide examples of such efforts to improve local places, both showing how a concerted cross-sectoral effort can set the stage for a healthier population. Pedroso et al.⁶ show data from Boston, Massachusetts, where the expansion of bicycling infrastructure was associated with a more than doubling of bicycle commuting coincident with a decrease in injuries. Rowland et al.⁷ show how a program that increases access to dental care in the community can be both cost-effective and a better approach to delivering quality care than the use of emergency departments for dental care, which would be normative absent such programs. The authors correctly note that this approach is a “patch” on the dental safety net system, which is a temporary approach to a challenge whose solution ultimately lies with a wholesale tackling of the challenges facing these communities—in many respects, the very goals of a Public Health 3.0 agenda. It will be important to see data emerge in coming years that inform this ambitious agenda, toward a genuine multisectoral engagement with the conditions that create health. We are both buoyed by the promise these approaches hold and anxious to ensure the political structures that ultimately shape our actions align to encourage and facilitate this work going forward.