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.

Thursday, August 16, 2012

Social Determinants of Health and the Public Health Enterprise

Recently my local newspaper (Louisville Courier Journal, August 9) published a story about high school graduation rates in Kentucky and the local public school system. The news article included recent statistics on the graduation rate in the local school system as a whole, as well as a Table showing the graduation rates of freshmen students in the individual high schools.  In the system as a whole, about 1/3 of freshmen don't graduate. The other very dismaying data in the article is the disparity in graduation rates between the school with the highest rate (Manual High School, 92%) and the school with the lowest rate (Iroquois High School, 40%). The article did not give details about the analysis methodology, so the possibility is that some of the students included in the non-graduation group later finish school in some other way.  Nevertheless, it is disturbing that so many young people fail.  Such failure to complete a high school education has a huge impact on youth for the rest of their lives, including the expectation of poor health status compared to their peers who have more success and achievement in school.

Not being a K12 educator, I'm sure there are some things about this problem that I don't understand.  Failure to graduate is a function of student effort and motivation, parental support, instructional practices and standards, curricular options (e.g. practical career training), student suspension rates, special education services, second language programs, school leadership, and many other factors.  The problem is not simple, which is why drop out rates do not change easily.

The reason I'm writing about this is not to shed light on how to solve the drop out problem, but to point out the glaring contrast between this huge social problem that has a significant impact on the public's health, and the fact that almost no role is being played by the public health enterprise.  Poor educational achievement is what we refer to as a "social determinant of health."  Students  who do not finish high school live, as a group, seven years shorter lives(Washington Post, March 11, 2008)  than others.  Along the way, they are likely to have more sickness and sick days and a poorer health-related quality of life.  There are not many threats to health that take a seven year toll, making high school drop out a giant threat to health.

And so we return to the public health enterprise.  How should we address education as a basic factor to promote health status?Indirectly we contribute to student success in school, but measures to promote child and adolescent health, such as with immunizations and health screening.  We are very comfortable with designing interventions with outcomes stated in terms of health status.  For example, to decrease the rate of hospital admission among children with asthma.  However, what if we made school success and high school graduation the outcome measure?  What then would be the role of the public health enterprise, and how would we proceed.

Rectifying the startling results of health inequity, and addressing the social determinants of health will require revolutionary change in the ways we deal with public health problems.  It will be an uphill battle, given the current social resistance to brave new enterprises undertaken by we the people in the form of government initiatives.