Public Health Has a Plain Language Problem

by Mark Miller

A few weeks after I started working at the de Beaumont Foundation, I was talking to a friend about the organization and our focus on public health. That led to the obvious question, “What exactly is public health?” I did my best to answer him, giving several examples and explaining what it is not, and I told myself, “I need a better answer for that.”

It turns out, the entire public health field struggles with that same question – and that’s a problem. If you can’t explain what you do and why it matters, how can you possibly build support and make others care? This lack of understanding is one of the reasons public health is underfunded and underappreciated, even though public health affects every person in the world, every day.

Professors Aaron E. Carroll and Austin Frakt recently wrote an op-ed for the New York Times titled “It Saves Lives. It Can Save Money. So Why Aren’t We Spending More on Public Health?” Citing numerous examples, they write: “Americans spend relatively little money in [public health] and far more on medical care that returns less value for its costs. Instead of continually complaining about how much is being spent on health care with little to show for it, maybe we should direct more of that money to public health.”

But even in this insightful commentary, Carroll and Frakt fall short in defining public health, describing it this way:

Public health “encompasses efforts made to improve the health of a broad population with investments not ordinarily considered ‘health care.’ For example, ad campaigns that encourage better health behaviors – like exercising or quitting smoking. Or efforts to improve housing and nutrition for low-income populations or the quality of air or drinking water for everyone. An obvious success is vaccines. In the 1900s, polio and smallpox were eliminated in the United States. Other diseases – such as measles, rubella, diphtheria – became very, very rare.”

This illustrates the communications problem, because it’s not a clear or compelling description. As with many other attempts to define what public health is, Carroll and Frakt focus on what it is not(health care) and then list vaccines and many other examples (car safety, workplace safety, clean water, and more). Defining public health as “not health care” is similar to the problematic term “nonprofit” – which describes mission-based organizations as “not businesses” instead of explaining what they are and why.

As with nonprofits, part of the challenge is that public health does so many important things. As our CEO Brian Castrucci asks, “We have all the ingredients, but do we know what we’re baking?”

In my next post, I’ll share preliminary findings of new research funded by the de Beaumont Foundation to explore this communications challenge and uncover opportunities to better define and promote public health.

Mark Miller is the Vice President of Communications at the de Beaumont Foundation.

Health Starts in the Community, Not the Clinic

by Brian C. Castrucci

We are fortunate to live in a nation where our healthcare system is filled with dedicated providers offering cutting-edge, innovative clinical care to prevent and control diseases. However, despite all the money we spend on health, the United States still lags behind other countries in terms of health outcomes such as life expectancy.

The reason this paradox exists may be found, in part, in an article summarizing a discussion recently held by the American Medical Association, “2 Ways to Spark Change in Minority Patients and Prevent Diabetes,” AMA Wire, June 18). The discussion focused on ways providers can encourage patients to take the steps needed to control their diabetes, but much of the advice is not practical for people who live in communications without access to conveniences that many of us take for granted.

As the head of the de Beaumont Foundation, which focuses on public health, and as a type 2 diabetic myself, I found the advice valuable but incomplete. In pursuit of the dream of “no new cases of preventable type 2 diabetes,” Dr. Niva Lubin-Johnson recommends that providers should “stress things the patient can control” like “diet, exercise, and getting enough rest.” She advises physicians to talk to patients about what they are willing to do, and she notes possible barriers to behavior change like time management. Because “it’s not easy for a single mother with school-aged children to go grocery shopping or find time to exercise,” she encourages providers to “spend the time to talk with them about how it can be done.”

While this advice is reasonable from a medical perspective, health professionals can’t ignore the indelible link between individual and community health. If we stop at simply identifying what the barriers are, and don’t intentionally look at why they are there, we miss a critical opportunity to address the root causes of chronic diseases like diabetes. A clinical approach alone to preventing diabetes — or any chronic disease — places the burden on the patient and his or her willingness to make necessary behavioral changes.

Yes, that single mother may have challenges finding time to exercise or go grocery shopping, but challenges with time management aren’t unique to any person or group in our culture. But maybe she doesn’t have access to places that offer affordable exercise options, or safe places to walk, bike, or run after dark, or grocery stores where she can buy fresh fruits and vegetables. Maybe her employer doesn’t have policies that allow her to take time during her workday to exercise, even though it might be in its best interest. (Each year, $90 million is lost in reduced productivity due to diabetes.) These community factors shape our individual choices, and no amount of talking can change them.

The truth is, health starts — and is sustained — in the community. If the places where you live, work, and play don’t allow you to achieve optimal health, there is very little that can be done in a doctor’s office that can change that. And that’s not a criticism of healthcare. It’s just a reality. A large percentage of Americans get a 30-minute wellness visit once a year, but what about the other 525,530 minutes?

To be honest, I am the type of person who would have benefited from the interventions Dr. Lubin-Johnson described. My community fully supported any choice that I wanted to make to improve my health. I have access to at least four large grocery chains that sell every fruit and vegetable there is. I can afford a gym membership and extended day care for my children. There’s a safe and well-lit park in my neighborhood with outdoor exercise equipment. In my case, it was my health choices — a poor diet and a general disregard for exercise — that led to my disease, but my behavior also led to control of my diabetes when I made better choices.

For people who have chronic conditions but don’t share my privilege, no amount of clinical intervention will make them healthy. Achieving and maintaining health requires the efforts of not only physicians, but also urban planners, housing experts, political leaders, educators, and many others. Only when we pair clinical intervention with smart policy and intentional planning will be able to envision a world free of preventable disease.

Discovering the Spectrum of Values in the Public Health Workforce

After spending this fellowship year learning about the public health workforce, I think about what type of career I will build as one of its newest members. Luckily, I have met inspiring and thoughtful public health practitioners who were willing to help me wrestle with big questions about where I may fit in the public health landscape. I’ve discovered what seem to be two ways in which public health workers are guided by their values in pursuing population health — one focused squarely on social justice and one incorporating a more diverse spectrum of moral foundations. These two sets of values are not competing; instead, they are similar in their ability to motivate public health practitioners and advocates to communicate our values and solve health challenges.

Fighting Injustice and Inequity
One nonprofit that represents public health values at work is Human Impact Partners (HIP), which, among other things, builds the capacity and leadership of the public health workforce to create healthy communities and a just society. HIP calls on public health professionals to lead and work with personal and professional values stemming from social justice. At the center of their philosophy is a dedication to communities, particularly those that are vulnerable. They imagine a public health workforce that is wholly committed to health equity and humbly centers their work on the voices of the community. HIP understands that health inequities result from lack of access to basic social and physical needs, which stem from power imbalances and forms of oppression, like racism. All of their work is inspired by this understanding. For example, they host webinars that instruct health department workers in health equity practice and how to engage with communities to build power.

I had the opportunity to speak with Jonathan Heller, one of HIP’s co-directors, who told me that the country needs people who are willing to put communities first and not compromise our values of social justice. When I asked Heller if there are any drawbacks to fighting for health equity in areas where people might not be ready to listen, he responded, “If not us, then who? If not now, then when?” This response speaks to the real and human consequences to health inequity. If public health wants to be a field that truly serves communities, we must act urgently to lessen the loss of life and livelihood caused by health inequality. Talking with Jonathan reminded me why I chose to study public health in the first place, after witnessing the destructive impact of the inequalities in health, education, and housing on families in St. Louis where I studied. HIP projects a vision of the kind of public health worker I want to be: one who focuses on the people I serve, prioritizes health equity, and leads with my values.

The Six Moral Foundations
Early on during my time at the de Beaumont Foundation, I met a group of public health lawyers, a health director, and a health system chaplain from North Carolina when they presented at a meeting of deputy state health officials. Their framework, “Crafting Richer Messages: Advocacy for Public Health Leaders,” represents another way of conceptualizing public health values and their role in public health practice.

The group’s work stemmed from the six moral foundations described by Jonathan Haidt in his book The Righteous Mind: Why Good People are Divided by Politics and Religion. The powerful revelation in Haidt’s research was that liberal-minded folks communicate primarily in the moral foundations of fairness, care, and liberty, while conservative communication tends to encompass the whole spectrum of the six moral foundations. This could explain the disconnect public health workers face when communicating public health work to conservative leaders; we forget to use the full spectrum of values. In this context, the “Crafting Richer Messages” framework presents an inclusive way for public health workers to work with partners of all political and ideological stripes, in order to find common ground and meet the shared goal of improving population health.

This operationalizing of moral foundations played out in a public health agency when Sue Lynn Ledford, the Wake County Health Director, helped pass 2016 legislation for a needle exchange program in North Carolina – in a heavily conservative General Assembly – in partnership with the NC Harm Reduction Coalition and the state law enforcement community. Together, these partners used persuasive arguments based on respect for law enforcement (authority) as well as appealing to the compassion for communities and families (care, loyalty, sanctity). Ledford listened to the values of lawmakers and communicated her position with moral foundations across the liberal/conservative spectrum, ultimately establishing a life-saving and highly controversial policy.

This work and the “Crafting Richer Messages” framework taught me that working across aisles, differences, sectors, and backgrounds is not a compromise of public health values, but an extension of them. As a public health worker, I will strive to speak many moral languages, so I can be an effective advocate for population health strategies.

Embracing the Spectrum of Approaches
The Human Impact Partners point due north, reminding the field of our highest ideals and greatest commitments. The “Crafting Richer Messages” initiative teaches us how to work inclusively with those we might not naturally agree with to make progress and improve lives. I see this spectrum of approaches to public health as an asset to the public health workforce, allowing us to solve problems from a variety of perspectives and with a variety of partners. As a result, I believe I can both stretch myself to communicate in all of the moral foundations, while still prioritizing the communities I serve.
What these approaches have in common is that they highlight the necessity of being a good partner in communities and engaging all the people we serve with humility and integrity. I still don’t know exactly where I fit in in the spectrum of these approaches, but asking these big questions about the public health field and workforce helps me imagine more possibilities and paths. When I consider what type of public health career I want to build, I know to look for opportunities that enable me to uphold my deeply held values, communicate in many moral languages, and partner with everyone committed to making a difference for the health of the public.

The New Public Health Generation: When I Grow Up, I Want To Be a Public Health Hero

I earned a master’s in public health (MPH) with a concentration in Behavioral Science and Health Education. Right out of school, I accepted the ASPPH Philanthropy Fellowship at the de Beaumont Foundation. One of the best parts of the fellowship has been meeting some of nation’s true “public health heroes.”

On my second day, I met Karen DeSalvo, who developed Public Health 3.0, which charts the future course of governmental public health in the United States. My second week, I met health commissioners from the nation’s 30 largest, most urban cities. At the APHA annual meeting, I was introduced to Jonathan Fielding, former health commissioner of Los Angeles, founder of UCLA’s public health school, and renowned author and public health thought leader. Just the other week I met the current Surgeon General, Dr. Jerome Adams, who is bringing nontraditional partners like business into the practice of public health. These are the gatekeepers to contemporary public health work and the future of the professional health field. I aspire to a career that builds on their work. However, all of these leaders hold medical degrees. I started to wonder if I made the right choice when I picked an MPH instead of an MD?

Health directors are often legally required to be a licensed physician. Looking back into the history of public health, this made sense. The causes of disease and disability were infectious, transmitted by bugs and bacteria and remedied by advances in medicine and epidemiology. However, today’s health directors need to know more than disease pathology. The leading causes of death are complicated chronic conditions that result from lifestyle and environment, and whose prevention requires new schools of knowledge. Health commissioners need to know about public transportation, access to healthy food, and clean air, none of which are covered in traditional medical training. Take, for example, a recent Lancet article that found that air pollution was responsible for 16% of all premature deaths worldwide (about 9 million). It’s not a medical approach that’s needed, but a systems approach working to build partnerships and pass policies that improve air quality. So, if the problems have changed, why do so many cities, counties, and states require still require a medical license?

Is my future in public health capped? Is my professional growth stunted already despite my passion and professional degree?  I began to search for other heroes who didn’t hold clinical degrees and found Colleen Bridger, the health commissioner of San Antonio. As a fellow non-clinical public health practitioner, I called her to learn more about her experiences and her career path.

Colleen Bridger, MPH, PhD, was appointed as health director of San Antonio in March of 2017. Before May 9, 2015, she wasn’t qualified for the job because the San Antonio city charter required that the city’s health director be a licensed physician. But, a public referendum in May 2015  eliminated this requirement. Dr. Bridger recalled being asked what she brought to the table as a public health professional without any clinical expertise. Her answer: she is able to look at the whole picture, understanding and solving health problems from the systems level, using a myriad of tools including policy. In this answer, Dr. Bridger highlighted what I’ve learned, the skills I gained without any clinical experience.

Dr. Bridger gained this system’s level perspective throughout her training in international development and public health, completing a PhD in health systems research and a dissertation in teen pregnancy prevention. Earlier this January, Dr. Bridger applied these skills when she led an effort to pass T21, which is one of the most effective methods of reducing tobacco use and its negative population health consequences, by raising the legal purchasing age to 21. I studied policies like T21; this is the type of work I want to do! I loved talking to Dr. Bridger because I relate to her. She started her career as a bilingual social worker and developed a passion for working and with vulnerable communities. There are a lot of stories like hers among young public health workers.

Dr. Bridger is excited about millennials entering the public health workforce because she says we are “natural systems thinkers”. At a time when zip code is the strongest predictor of health status, system thinkers are needed to create healthy communities. A drive for social change motivates a lot of young people like me to get into public health. I was 1 of 20,000 public health graduates in 2016, of which less than 1 of 10 intended to pursue a medical degree. There are more young workers pursing public health degrees than ever before. We need constructive, upwardly mobile career paths in governmental health agencies in order to become the next generation of “heroes” in public health.

The public health workforce is a team of public health professionals, policymakers, doctors, activists, and researchers of all backgrounds. As Dr. Bridger puts it, “there is something in it for everybody”. However, the MD requirement is a structural barrier that could prevent me, and others like me, from leading in the field. Policy needs to catch up with a changing workforce and changing health landscape by shedding the MD requirement for health agency directors. I still wonder if I made the right choice when I decided against pursuing medical school. But when I reflect on the progressive changes proposed by Public Health 3.0 and talk to public health heroes like Colleen Bridger, I am confident enough in my public health training to someday consider the health director position myself.

***

This year I am blogging about my experience as a fellow and what it means for the millennial generation to join and change the public health landscape. I will grapple with the changing public health workforce, interview leaders in and out of the field, and discuss the future of public health as my generation sees it. Follow along!