You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010


Wednesday, August 29, 2012

Policy and Freedom

Recently I was reading a mission statement from a nearby local public health department.  Their mission, although they labeled it their purpose, was to "change the public's health, one person at a time." Without being hateful or combative about it, that mission entirely misses the concept of public health.  The public health enterprise organizes itself to impact whole communities, whereas clinical health services are designed to efficiently serve one patient at a time.  We need both doing what they do best, not both systems doing the same thing.  It is dismaying to me that even among health promotion and public health professionals, there is still lots of fuzzy thinking about what we do.  Albert Einstein is quoted as saying "Perfection of means and confusion of ends seem to characterize our age."  It is still true, except we are also confused about means.

So what are we good at, and how can we have the greatest impact on the public's health?  A change has come about in the way we think about public health interventions. Whereas in all the years going back to at least the 1960s, the social and behavioral sciences component of public health has been about designing health behavior change programs.  The toolset for this was education and communication programs for communities.  More and more, leadership (such as at CDC) is moving away from traditional community programs.

The coin of the realm is now policy and environmental strategies.  Thomas Frieden, Director of CDC, asserts that education and counseling are largely ineffective, to be used only when interventions lower on the food chain, or to switch metaphors, more upstream, are unavailable.  While I don't fully agree with Director Frieden, one cannot argue that policy does not have huge potential to promote the public's health, and to do it more effectively and efficiently than behavior change programs.  In my view, we need to do all of the above, because the complexity of public health problems requires it.  Nevertheless, I want to discuss the policy emphasis in the current social and political climate.

Policy solutions to public health problems often require ending or curtailing actions on the part of individuals and organizations, such as businesses:  The prohibition to sell cigarettes to those younger than 21 is an example.  Policy solutions sometimes dictate individuals and organizations bear a cost as part of the policy: Requiring restaurants to provide calorie facts on menu boards is an example.  Actions such as these create an entirely different response then the communication campaigns that rely on people making better voluntary choices based on information provided.  Nevertheless, in the not too distant past, people were much more comfortable with government public health agencies using policy tools.  There was a sense that we accept some personal limitations for the greater good.  That social ambiance seems quaint and naive in 2012.

As represented by rhetoric coming from partisan campaigns and positions articulated by political parties and advocacy organizations, there is an ascendency of the view that personal freedom trumps every other value.  Large segments of society bridle against using the power of gevernment to make policies for enhancing the public's health.  Those of this persuasion resent any limitation of their freedom and reject the legitimacy of prosocial taxation and spending by governments.  They are skeptical of the notion that government can be a valuable tool by which we all work together to solve problems for everyone.  Freedom is the new byword, code for shrinking government (including public health) and stripping away its power.

We obviously suffer from poor timing.  Just at the time when the public health enterprise is putting great stock in policy solutions, there is a perfect storm of opposition to the legitimacy of government.

This emphasis on policy formation and advocacy is slowly moving into the Schools of Public Health and academic training programs.  In the current environment, we need to be teaching not only the mechanisms and values of policy solutions, but also how to be skillful in confronting the deep and apparently growing resistance to any expansion of government action.  In my experience, academics are not very good at hard-ball politics, so it will be a significant challenge to help our students use their citizen freedoms to advance the public health policy agenda.

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