The Aspirations and Strategies of Public Health.

This Dean’s Note is co-written by Professor George Annas.

A few weeks ago, we published an essay called “Aspirations and Strategies for Public Health.” Here we reproduce some of the arguments in that essay, in extended form, simply because many of the thoughts therein seem directly relevant to our ongoing School discussion.

We start with a fundamental premise. Public health is responsible for extraordinary achievements over the past century and could make similar critical contributions to health in this century; this track record of success would seem to make public health the logical choice to address new challenges to life and health in a changing world, including chronic diseases, increasing income disparities, the threat of bioterrorism, and climate change.

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Why is this the case?

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This agenda is, in our assessment, too narrow, and is responsible for public health losing ground to medical concerns in the national conversation. The bold goals articulated in the definitions of public health will never be met, or even taken seriously, if public health itself abandons or severely limits them. Tension between the bold roots of public health and its uncertain operational manifestation has allowed public health to recede in collective consciousness, as a burgeoning medical agenda has moved to the forefront. A lack of clarity about public health’s purpose has also muddied its actions and depressed its aspirations.

So what aspirations can invigorate what we already do well and nudge us into areas of innovation? We suggest two aspirations that are informed by our understanding of the state of the field, the challenges it faces, and the threats to public health we see facing us going forward.

First, public health continues to be about the conditions that make people healthy, and thus must unstintingly engage the social, political, and economic foundations that determine population health. Although creating the conditions that make people healthy is universally acknowledged as a central goal by most prominent definitions of the field, it remains perhaps the most difficult purpose for public health to seriously grapple with. The challenge is that the conditions that make people healthy often are outside what we have historically considered the remit of the health professions. For example, there is ample scholarship that has documented the core role of both income distribution and racial segregation as drivers of population health. A focus on the conditions that make populations healthy requires entanglement with issues that reflect political and social structures. Such an engagement is freighted with peril, both conceptually and operationally.

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Given these aspirations for public health, what are the best strategies to meet them? We suggest four that offer a way forward.

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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 and increasing the length of life regardless of quality of life. The medical agenda is clear. A lack of clarity about the purpose of public health has made us less effective than we could be. We suggest that identifying two core aspirations and four strategies for public health can help shape our resolve towards public health achievement in the remainder of the 21st century.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea

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