by Edward L. Hunter
Decision-making in the real world relies on a complex mix of inputs, and public health policy is no exception. Because I write this as the de Beaumont Foundation is releasing our first documentary short (“Public Health & Politics: Examining the Surgeon General“)and because we need a variety of superheroes in public health, I’ll call these inputs Truth, Justice, and the American Way.
- Truth, because policy should be informed by solid evidence, and public health professionals strive to find the best evidence to inform decisions.
- Justice, because the field of public health is guided by the mission to make people safer and healthier, including addressing underlying social determinants of health that disproportionately limit opportunity in many populations.
- The American Way, because, well, that’s the way we make public policy decisions in the uniquely American system that has evolved since 1776. Importantly, there are many competing values and considerations in policy-making.
The examination of the role of the US Surgeon General in “Public Health & Politics” reinforces how important it is to have a clear, unambiguous voice speaking on behalf of science and public health evidence – in effect, someone to anchor us to truth – in this mix.
Real World Decision-Making: The American Way
The US system of government is almost designed to ensure conflict: it is pluralistic, relies on multiple levels of government, has checks and balances built into every level of decision-making, and needs to balance public and private interests in important decisions. The American version of democracy encourages a rough-and-tumble exchange of ideas and interests, in which truth and justice don’t always hold the upper hand.d
Spoiler alert: political discourse sometimes has a tenuous relationship with the truth.
Public health professionals, particularly those in government, need to understand these competing forces and seize the opportunity to bring public health values and evidence into this dialogue. My recent commentary “Politics and Public Health: Engaging the Third Rail” discusses concrete strategies for public health officials to bridge the divide between the political system and governmental public health.
Public health seeks justice but is grounded in science. As public health seeks to engage in the policy process, it is essential that it bring clear, unadulterated evidence into the ring as it grapples with the political decision-making process.
I developed my appreciation for unadulterated evidence as an official with the CDC’s National Center for Health Statistics, where we aspired to be in the truth business. Like our counterparts producing unemployment statistics or economic indicators, our mission was to produce unbiased data – regardless of where the chips fell. Not only were we guided by professional standards, but we had the weight of OMB guidelines and federal laws regulating government statistics to protect the integrity of the system. Our ideal outcome was to stimulate a debate over the implications of the evidence, but not the truth of the findings.
A Surgeon General occupies this same space, but with different tools and audiences. Speaking on a broad range of health, medical, and policy concerns, the Surgeon General must be viewed as authoritative and knowledgeable – and must always be viewed as source of advice untainted by politics and other influences. The Surgeon General should speak with clarity and credibility to the American People while demonstrating the strength and credibility to speak truth to power. Other government health officials must be held to high standards as well, but few have jobs where their singular role is to be the voice of evidence and science.
As important as evidence is in seeking the “truth,” it’s also important to recognize the limits of public health science and to communicate those limits. Data is limited by many factors, beginning with choices we make in what to measure; because of methodological limitations, research is often suggestive but not definitive. Even more broadly, our understanding of the “truth” is influenced by our values and perspectives; one person’s truth may be another’s heresy, particularly when facts are interpreted in the context of overarching values. This reinforces the need for public health officials to be objective, forthcoming about the limits of public health evidence, and respectful of how different audiences interpret evidence.
Who do you trust?
Our new documentary short explores the complexities of the role of the Surgeon General as it has evolved over time. (See the trailer.) As an official whose term overlaps Presidencies, the Surgeon General has the rare ability to operate outside the constraints imposed on most Presidential appointees. Nonetheless, Surgeons General can’t escape the fact that they work inside government, regardless of who controls the White House, and have experienced a variety of direct and indirect pressures and even challenges to their independence as a result.
With the 2007 House hearing on politics and the Surgeon General as a backdrop, this documentary explores how Surgeons General have grappled with these complexities over time. We draw on the experience and reflections of Surgeons General Koop, Satcher, and Carmona, with additional perspective from American Public Health Association President Georges Benjamin.
Public health needs superheroes at all levels, as our goals are larger than any one position or leader. We need truth tellers to be assured that we have an independent Surgeon General at the national level and trustworthy health officials at the federal, state, and local levels. We need to stay focused on our mission to improve health across the entire population. And we need to engage in dialogue with policymakers, helping to ground decisions in evidence as we navigate the real-world dynamics of the American system.