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February 16, 2016

Aspirations and Strategies for Public Health

Author Affiliations
  • 1Office of the Dean, Boston University School of Public Health, Boston, Massachusetts
  • 2Center for Health Law, Ethics, and Human Rights, Boston University School of Public Health, Boston, Massachusetts
JAMA. 2016;315(7):655-656. doi:10.1001/jama.2016.0198

Public health is responsible for extraordinary achievements over the past century, such as remarkable gains in life expectancy and substantial decreases in infectious disease mortality, and could make similar critical contributions to health in this century. Public health should be ascendant, but ample evidence suggests that it is on the defensive today, underappreciated, and underfunded. Government actions to improve the health of populations are widely suspect, as illustrated by the controversies involving efforts to curb soda container sizes in New York City, state and federal efforts to limit reproductive health rights, and global efforts to address climate change.

By contrast, traditional medicine continues to be privileged. The burgeoning precision medicine agenda and the continuing emphasis on the treatment for cancer have captured the imagination of funding agencies and politics at the highest levels. The result is diversion of resources in the direction of individualized efforts at disease prediction through genomic approaches, and away from the structural changes with broader population-based effects that have long characterized public health action. Public health is not alone, sharing funding and infrastructure deficiencies with transportation, education, and even public safety (eFigure in the Supplement).

The Challenge to Public Health Aspirations

Definitions of public health have long been criticized as either overly broad in subject matter or too narrow in operation.1 Nonetheless, the challenge to public health does not center on its goals. Protecting and promoting the health of populations has always been, and remains, a widely accepted and valued mission and is at the center of all mainstream definitions of public health.2

This challenge is 2-fold. First, public health has inexorably shifted its focus to the operational aspects of disease surveillance and control without sufficient recognition of the aspirational, population-health, purpose-driven mission. Maintenance of core functions and activities cannot constitute the future; rather it suggests doing more of what worked in the last century in a different, rapidly changing environment. It has been suggested, for example, that public health should “expand its past successes to further reduce tobacco and alcohol use, control persistent infectious diseases, increase physical activity, improve nutrition, and reduce harms from injuries and other environmental risks.”3

Second, exacerbating this challenge, in high-income countries, the “easy” work of public health is done—sanitation, vaccination, and response to epidemics that form the bedrock of a healthy society are largely in place and have been successful. The health problems of the 21st century, including the increased prevalence of chronic illnesses and the challenges of healthy aging, are more complex. These problems require solutions at the interstices of social, political, cultural, and economic domains where public health’s role shifts from acting alone to engaging as a coordinator and motivator of various, sometimes unusual, partners in sectors not directly responsible for health. This suggests that an agenda that focuses on core operations of traditional public health functions has become too narrow and is responsible for public health losing ground to medical concerns in the national conversation.

Public health’s bold population health improvement goals will never be met, or even taken seriously, if public health shifts its attention away from these goals. To invigorate what public health already does well and nudge the field into areas of innovation, public health should strive to meet 2 major aspirations that are informed by the state of the field, the challenges public health faces, and the current and future threats to public health.

Public health must engage the social, political, and economic foundations that determine population health (Box 1). The conditions that make people healthy often are outside what have historically been considered the remit of the health professions: health improvement now requires participation in politics and social structures. Such engagement is much more perilous than traditional efforts to maintain population health such as sanitation, food safety, and response to epidemics. Operationally, engaging issues such as racial segregation in housing and education requires clarity of advocacy by the public health professionals who must, to be effective, work with media, business, and academia, as well as in the governmental public health infrastructure. This will require a boldness on the part of public health, and the reliance on agents of public health action, such as universities, that are less beholden to political pressures in establishing their budgets and their educational and research agendas.

Box Section Ref ID
Box 1.

Aspirations for Public Health

  • 1. Take a leadership role in confronting and influencing the social, political, and economic factors that determine population health to sustainably protect the health of the public against old and new threats.

  • 2. Take a leadership role in reducing inequities by working to narrow health gaps across groups in ways that promote social justice and human rights.

In addition, public health must balance overall improvement of population health with the achievement of health across groups and the narrowing of health gaps. Although the roots of public health align with efforts to promote health among vulnerable and marginalized populations, public health has achieved broad acceptance through an unstinting focus on improving the health of the aggregate, making populations healthier. Nonetheless, health inequities remain at the core of the conceptual underpinning of why public health leaders and practitioners do what they do, and the drivers of these inequities are the same drivers that have animated some of the difficult national social justice conversations that have resurfaced in the past few years. It stands public health in enormously good stead to be at the forefront of this national conversation, to engage in the foundational drivers of health, and to change a national conversation around health, in the service of public health’s aspirations.

Public Health Strategies

What are the best strategies to meet these aspirations? Four main strategies offer a way forward (Box 2). First, the breadth of public health engagement requires relentless prioritization, engaging both intellectually and pragmatically with the core question of what matters most to the health of populations. This question is time-specific and subject to change. As Vickers suggested in 19584: The “critical and ubiquitous question [is] what matters most now?” Setting and changing priorities will require rethinking how intellectual work is approached and accomplished, and how that work intersects with the actions of public health.

Box Section Ref ID
Box 2.

Public Health Strategies for the 21st Century

  • 1. Relentlessly prioritize actions to do what matters most to the health of populations.

  • 2. Engage the mechanisms that explain how core foundational structures produce population health.

  • 3. Move from government-dominated public health to multisectorial public health.

  • 4. Formally adopt the Universal Declaration of Human Rights as the Code of Public Health Ethics.

Second, practitioners of public health must actively engage the mechanisms that explain how core foundational structures produce population health. This argues for a perspective that seeks balance, navigating the importance of understanding and intervening on mechanistic processes, without losing sight of the core foundational drivers that will determine the sustainability of any progress. Public health would do well, for example, to be a part of a conversation that engages “-omics”-related research, while recognizing that the translation of this research is likely to be a rather small piece of a much more complicated production of health of populations.

Third, the vision of public health as solely a government-mandated and financed activity is rapidly evolving, and public health advocates must work with actors across government, academia, industry, and not-for-profit sectors to achieve the goals of public health. Public health should be at the forefront of generating and sustaining a broad national and global conversation around centrality of population health to all well-being. This will require substantial engagement in education, both of traditional partners across sectors and of a broader public and stakeholders. It also requires elevating health in public consciousness and recognizing that individual health has a glass ceiling without an improvement in the health of the collective.

Fourth, public health needs an ethic to help guide its practice. The fact that much of public health is still directed by governments suggests that human rights, as articulated in the Universal Declaration of Human Rights, provides a solid ethical framework for public health practice.5 In practice, many in public health have already adopted human rights as the primary guide for their work. This is because not only do human rights include a “right to health” for all people, they also provide a wide array of government obligations to “respect, protect, and fulfill” the rights of people in ways that directly promote population health and advance social justice.

The potential of public health to continue to improve the health of populations is being challenged and undermined by multiple factors, including an overemphasis on curative medicine. A lack of clarity about its population-centered purpose has made public health less effective than it could be. Identifying 2 core aspirations and 4 strategies for public health can help shape the resolve toward public health achievement in the remainder of the 21st century.

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Article Information

Corresponding Author: George J. Annas, JD, MPH, Center for Health Law, Ethics, and Human Rights, Boston University School of Public Health, 715 Albany St, Boston, MA 02118 (annasgj@bu.edu).

Published Online: January 28, 2016. doi:10.1001/jama.2016.0198.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
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American Public Health Association. What is public health?https://www.apha.org/what-is-public-health. Accessed November 12, 2015.
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Frieden  TR.  Shattuck lecture: the future of public health. N Engl J Med. 2015;373(18):1748-1754.
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Vickers  G.  What sets the goals of public health . N Engl J Med. 1958;258(12):589-596.
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Mann  JM, Gruskin  S, Grodin  MA, Annas  GJ, eds. Health and Human Rights: A Reader. New York, NY: Routledge; 1999.
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