Wednesday, September 6, 2017

The Work of Public Health

The Work of Public Health – Labor Day 2017

“A summary of the problems in our culture is that we made three bad philosophical bets along the way: we chose (Thomas ) Hobbs when we should have chosen (Émile) Durkheim, we learned to think of ourselves as individuals when we are really relationships – too individualistic and not communitarian; we chose (René) Descartes when we should have chosen Augustine (of Hippo), we think of ourselves as primarily cognitive feeling creatures when we’re primarily emotional longing creatures; and we chose (Jeremy) Bentham when we should have chosen (Viktor) Frankl, we think our lives are organized around pleasure and pain but really our secret and deepest desires are purpose and meaning.” -David Brooks, 2017 Aspen Ideas Festival Lecture

In the late 1970s and 1980s American society made some philosophical choices that altered the course of our collective history. The field of public health and the health of our society were particularly affected by those choices.

We had just lived through two tumultuous and chaotic decades. We had experienced the Vietnam War, the War on Poverty, culture wars, the Great Society Program, and movements for civil rights, women’s rights, and environmental protection. We had seen the rise of Black Power, Flower Power, feminist power, and community power. We had witnessed the emergence of the idealistic, obstreperous, and numerically powerful Baby Boom generation.

Amidst the turmoil and conflict of those years were some dramatic and positive changes in our society including expansion of voting rights, acknowledgment of civil rights, drafting of environmental protection laws, decreased poverty among the aged, expanded healthcare access, improved health status, and narrowing of health disparities. Yet, all of these changes were disruptive and a direct challenge to the political, economic, and cultural status quo.

We became uncomfortable with the disorder within our country and longed for stability. This desire led us to a crossroads of philosophical directions for the future. In the health sector, seduced by the promise of scientific and technological miracles, we chose a biomedical rather than a public health perspective. That choice mirrored those in all other sectors. We chose boot straps individualism rather than interdependence and social cohesion. We chose competition and free market solutions rather than solutions based on social responsibility and social justice. We chose to demonize government rather than recognize its critical role. We chose to invest in technology and specialists rather than support generalists.  And we saw structural discrimination as a thing of the past rather than a challenge for the present and future.

These choices brought us unimaginable technological advances and great rewards for some. But those came at a very steep price both financially and socially. Despite healthcare costs far exceeding those of any other country, we’ve been steadily falling behind in the basic indicators of good health status – longevity and infant mortality. We have increasing disparities in all sectors of our society, particularly those that impact health – income, education, housing, incarceration, and environment. We have disintegrating urban and rural communities. We have a rise in the diseases of despair (drug and alcohol use, suicide, mental illness among others) that threaten the long-term health of our society. We have a changing climate that threatens our very existence. And we have a rise in fear, hate, and discrimination that is destroying our sense of community and social cohesion that will be essential in creating a livable future.

Like David Brooks, I believe we made some bad philosophical choices that have negatively impacted our society. But like the late 1970s and 1980s, we are at a crossroads.  We are in a time of turmoil and chaos and we again have the opportunity to choose the philosophical direction that we will take as a society. This time I hope we choose a direction that is more “communitarian” and one that gives our activities “purpose and meaning.”

I believe that our public health work is to collectively be the contemporary Durkheim, Augustine, and Frankl of public health. We must demonstrate that many of the choices that we’ve made are not socially, economically, or environmentally healthy for our country, our planet, or their inhabitants. Our greatest challenge is to build the public will to work collectively to assure the conditions in which all people can be healthy – conditions built on the philosophy of social responsibility, social cohesion, and social justice.