Monday, September 26, 2016

The Ark of Public Health

Midway through the 2016 annual meeting of the Association of State and Territorial Health Officials (ASTHO) being held in Minnesota, 180 attendees headed to the Mississippi River for an evening of socializing. Despite the dark clouds forming overhead, people were ready, after a day of discussing difficult public health issues, to venture from the conference hotel to spend time interacting informally with colleagues from around the country. Two by two, they filed across the gangplank of an old-fashioned paddle boat for a three-hour scenic and music-filled cruise from St. Paul to Minneapolis and back.

Two by two they came bringing the perspectives of red states and blue states, liberals and conservatives, moderates and progressives, reformists and libertarians, east and west coasts, northern and southern boarders, new professionals and seasoned veterans, executives and line staff, academicians and practitioners, federal and state/local agencies, policy makers and program implementers, racial and ethnic minorities and majorities, men and women, straight and LGBTQ, optimists and pessimists, lumpers and splitters, and a myriad of professionals dealing with issues from AIDS to Zika. Two by two came a menagerie of public health workers with one thing in common (in addition to a desire to have some fun) – a public health vision of how to protect and improve the health of everyone in our society.

One hour into the trip a lightning-created extravaganza rivaling the northern lights filled the sky. Despite its awe-inspiring beauty, the lightening presaged a huge storm. Before long, the deluge arrived forcing everyone into the deckhouse. Sheltered from the rain in a boat equipped to weather this “once in 500 years” storm, the party and the trip continued. Although this storm was not of “biblical proportions,” the analogy was not lost on many of the passengers – it was certainly not lost on me.

As I sat on the boat with my public health colleagues watching the lightening and rain, I reflected on the numerous challenges facing our world: climate change, war, terrorism, interpersonal violence, economic inequities, educational and health disparities, racism, homophobia, religious intolerance, antibiotic resistant organisms, new infectious diseases, burgeoning chronic diseases, and the aging of our society to name just a few. Yet, the approach that we’ve taken over the last several decades has been remarkably ineffective in addressing these issues. Something needs to change. Perhaps it’s time for a new approach – an approach based on the public health principles embraced by the people sequestered on the boat.

Our current approach is built on a worldview anchored on the principle of individualism. From this evolves our reliance on market justice and free market solutions where competition is embraced with its attendant winners and losers and disparities are considered to be due to an inability to effectively compete rather than discrimination. Not surprisingly, health is seen as an individual responsibility. This worldview has led to great technological advances, powerful corporations, and a global economy. It has also fostered the development of a large and expensive health care system to treat individuals when they become ill or disabled. It has also led to huge disparities in wealth and health and to the erosion of social cohesion. Investments in public health and human services have suffered with this approach.

An alternative worldview, one based on public health principles, might provide a better framework from which to address today’s problems. This worldview is community-based and anchored on a shared responsibility for improving health and well-being. It is based on the principles of social responsibility and social justice where cooperation and collective action are essential to improving the well-being of all members of society. Discrimination and disparities are acknowledged and not seen just as individual shortcomings but as societal failures to provide equitable opportunities to thrive. Although this worldview is not currently dominant, it was at other times in our past and it fostered significant benefits for our society. Perhaps it’s time to adopt this alternative worldview in plotting our course for the next 50 to 100 years.

Pondering this notion of worldview, I recalled this statement by Wendell Berry, a Kentucky farmer and poet: “We have lived by the assumption that what was good for us would be good for the world. We have been wrong. We must change our lives so that it will be possible to live by the contrary assumption, that what is good for the world will be good for us.” This mirrors what Minnesota Senator Paul Wellstone said: “We all do better when we all do better.” This is the philosophy behind public health.

To set aside the dominant worldview in this country and adopt a public health worldview will require a huge shift in societal attitudes. Yet, every day we are being flooded by seemingly intractable problems that are threatening and frightening everyone. Perhaps now is an opportune time to wash away our current approach and make the case for a fresh one, a public health approach, to our contemporary and approaching challenges.

The sky cleared and the rain ended just as the paddleboat docked. As people left the boat, there was a sense of cohesion, community, and optimism among the group. Maybe I was mistaken, but I sensed that this group of public health leaders felt energized and empowered to take on this challenge of creating a vibrant and equitable new world where everyone has the opportunity to be healthy. What better group than public health workers to lead this change two by two, four by four, eight by eight …

Ed