Rachel's Democracy & Health News #850, April 13, 2006


[Rachel's introduction: By adopting a "public health perspective" we could all find many new allies, connect our favorite issues with other people's favorite issues, and thus build a stronger, multi- issue movement to champion environment, health, democracy, and justice.]

By Peter Montague

I'll define public health in a minute. But first, "Why does public health matter?"

Public health matters because

** Many of us are spending our lives working on public health problems without necessarily recognizing that that's what we're doing.

When we worry about mercury in fish, the effects of diesel exhaust on asthma, lead paint in housing, schools built on toxic waste dumps, or workers getting leukemia from benzene -- we are worrying about the same kinds of problems that public health workers have been tackling since about 1850. Long before there was an Environmental Protection Agency (created in 1970), public health workers have been trying to make the environment (broadly defined) safer for humans.

** Remarkably, most of us are working on public health problems without building any bridges to the public health professionals and institutions that have been focused on related "environment and health" problems since 1850 or, in some cases earlier. (Baltimore established its public health department in 1798). As a result, we are not supporting the public health system, which definitely needs our help -- and we are failing to connect with a group of powerful allies who could help us advocate for our issues.

** We could all benefit from adopting the "public health perspective" -- which openly acknowledges that three environments influence human health: the natural, the built, and the social. Public health workers acknowledge that human health is powerfully influenced by water and air (nature) and by asbestos and diesel fumes (the built environment), but they also acknowledge the powerful influences of low income, social isolation, pyramids of status, poor education, stressful jobs, depression, and the sense that one's life is out of control.

By adopting a "public health perspective" we could all find numerous new allies, connect our favorite issues with other people's favorite issues, and thus build a stronger, multi-issue movement to champion environment, health, democracy, and justice. This is not as far- fetched as it may sound to some who have grown cynical or despondent about the possibilities for social change. Hear me out.

** Finally, public health matters because the main idea propelling public health practice has always been prevention.[1] Thus a modern precautionary (preventive) approach to environmental protection is entirely consistent with the historical mission of public health, which can be summarized succinctly as "prevention."

Why is prevention important? Because, as Ronald Wright says in his important little book, A Short History of Progress, "Like all creatures, humans have made their way in the world so far by trial and error; unlike other creatures, we have a presence so colossal that error is a luxury we can no longer afford. The world has grown too small to forgive us any big mistakes."

So prevention is more important than ever before, prevention has always been the basis of public health practice, and now -- with the advent of the precautionary principle -- prevention is becoming the basis of modern environmental protection.

In sum, the precautionary approach to "environmental health" problems can be informed and energized by many aspects of public health practice, and the public health system could be revitalized and given new purpose by joining forces with environmental health advocates.

So what is public health?

In Chapter 1 of his graduate-level textbook, Public Health, What It Is and How It Works -- now in its third edition -- Bernard Turnock offers several "visions" of public health that various people share:

** It is literally the health of the public -- our success at curbing infectious diseases (diphtheria, polio) and our less-successful efforts to eliminate chronic disorders (cancer, diabetes, depression), and to foster good health through exercise, nutrition, decent workplaces and friendly neighborhoods.

** It is the professionals who staff public health departments -- who offer flu vaccines, make sure restaurants meet minimum health standards, try to minimize lead poisoning among children, staff clinics screening for AIDs, discourage smoking, and so on.

** Public health is the body of knowledge and techniques used by public health workers -- the laboratories for making vaccines; the systems for collecting and analyzing data on rates of disease and death; the brochures that emphasize for school children the importance of washing their hands. and so on.

** The government services that aim to give everyone access to basic medical care -- emergency rooms, nurses who make home visits, food supplements for low-income families with children, clinics offering prenatal care, and so on.

But most importantly, says Turnock, public health is

** "A broad social enterprise, more akin to a movement, that seeks to extend the benefits of current knowledge in ways that will have the maximum impact on the health status of a population. It does so by identifying problems that call for collective action to protect, promote, and improve health, primarily through preventive strategies."

Turnock goes on: "This public health is unique in its interdisciplinary approach and methods, its emphasis on preventive strategies, its linkage with government and political decision making, and its dynamic adaptation to new problems placed on its agenda."

And, he says, "Above all else, it is a collective effort to identify and address the unacceptable realities that result in preventable and avoidable health and quality of life outcomes, and it is the composite of efforts and activities that are carried out by people and organizations committed to these ends."

Turnock then examines three famous definitions of public health. Here we find good reasons for locating "environmental health" and "chemicals-and-health" in the mainstream of public health thinking.

The first definition was provided in 1988 by the Institute of Medicine (IOM), which is one of the nation's prestigious National Academies. In its study, The Future of Public Health, the IOM defined the mission of public health as

"Fulfilling society's interest in assuring conditions in which people can be healthy."

Obviously, within that definition, you can easily locate "mercury in tuna," or "toxicants in baby toys" or "lead in paint" but you can also find "school lunch" and "livable wages" and "decent working conditions." If society has an interest in "assuring" "conditions in which people can be healthy," than public health is a broad social movement indeed -- much broader, in fact, than "chemicals and health" or "environmental health." Are you seeing the possibilities here?

Turnock comments on the IOM definition of public health: "This definition directs our attention to the many conditions that influence health and wellness, underscoring the broad scope of public health and legitimizing its interest in social, economic, political, and medical care factors that affect health and illness."

He goes on, "The definition's premise that society has an interest in the health of its members implies that improving conditions and health status for others is acting in our own self-interest. The assertion that improving the health status of others provides benefits to all is a core value of public health."

Another enduring definition of public health -- widely accepted and quoted today -- was published 85 years ago, in 1920, by C.E.A. Winslow.

"... the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and for the development of the social machinery to insure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity."[2]

Turnock comments on Winslow's definition: "The phrases, 'science and art," 'organized community effort," and 'birthright of health and longevity' capture the substance and aims of public health.... His allusion to the 'social machinery necessary to insure everyone a standard of living adequate for the maintenance of health' speaks to the relationship between social conditions and health in all societies," says Turnock.

Turnock then offers a third simple definition of public health:

"If public health professionals were pressed to provide a one word synonym for public health, the most frequent response would probably be prevention. In general, prevention characterizes actions that are taken to reduce the possibility that something [bad] will happen or in hopes of minimizing the damage that may occur if it does happen."

Here we can see the connection between public health and what I call "modern environmental protection," which I believe is based on the precautionary approach -- the approach that aims to prevent harm rather than justify harm after the fact using numerical risk assessment or other means. At their core, the precautionary approach and the public health approach are one and the same.

Those who have begun to adopt a precautionary approach will almost certainly feel a strong connection to the central purpose, the history, and the philosophy of public health. And, one hopes, the public health community can begin to recognize that the environmental health advocacy movement represents a huge untapped wellspring of energy, resources, and talent that could "go to bat" for public health, to restore and rebuild the budgets and the infrastructure of our public health institutions.

Because it is prevention oriented, public health does not always have a strong, vocal constituency, calling on decision makers to maintain its staff, its facilities and equipment, its capacity to prevent disease and injury. You can imagine a rally to "Get toxic chemicals out of baby toys" -- but it is harder to imagine a candlelight vigil attracting all the people who have not gotten diphtheria as a result of public health advances of the last 50 years.

As Turnock points out, the largest number of beneficiaries of public health can never show up at a public hearing and can never write a letter to the editor praising their health department because they have not yet been born. The public health movement is constantly working to make sure the world our children inherit is a decent place. But often theirs is a thankless job.

Still, prevention is a highly-regarded purpose of public health. Turnock reports polls showing that

* 91 percent of all adults believe that prevention of the spread of infectious diseases such as tuberculosis, measles, flu, and AIDS is very important

* 88 percent also believe that conducting research into the causes and prevention of disease is very important

* 87 percent believe that immunization to prevent diseases is very important

* 86 percent believe that ensuring that people are not exposed to unsafe water, air pollution, or toxic waste is very important

* 85 percent believe that it is very important to work to reduce death and injuries from violence

The Basis of Public Health Practice is Social Justice

Importantly, public health has been built on a solid philosophical foundation of fairness and social justice. Thus a "justice perspective" is built into public health, and this provides a natural bridge to "environmental justice."

As Turnock says,

"It is vital to recognize the social justice orientation of public health and even more critical to understand the potential for conflict and confrontation that it generates. Social justice is said to be the foundation of public health. The concept first emerged around 1848, a time that might be considered the birth of modern public health.

"Justice is an abstract concept that determines how each member of a society is allocated his or her fair share of collective burdens and benefits. Societal benefits to be distributed may include happiness, income, or social status. Burdens include restrictions of individual action and taxation. Justice dictates that there is fairness in the distribution of benefits and burdens; injustices occur when persons are denied some benefit to which they are entitled or when some burden is imposed unduly.

"If access to health services, or even health itself, is considered to be a societal benefit (or if poor health is considered to be a burden), the links between the concepts of justice and public health become clear."

Turnock then makes a statement that I believe is extremely important for the environmental health movement to consider:

"Extending the frontiers of science and knowledge may not be as useful for improving public health as shifting the collective values of our society to act on what we already know."

Shifting the collective values of society to act on what we already know.

Think about that. It tells us that our goal is not to pass one law or another or enforce one regulation or another (though those might be secondary results of our work). Our primary goal could be -- and arguably should be -- to shift the values of society... to what?

Perhaps to these basic goals:

** To make it repugnant and unthinkable to harm public health or nature any more than is minimally necessary to achieve our human purposes;

** To make it repugnant and unthinkable to deprive anyone of liberty, equality, or democracy any more than is minimally necessary to achieve our human purposes.

Achieving these broad goals would require deep cultural shifts toward the acknowledgment of limits, the value of sharing, and the essential modern requirement for prevention.

In his important essay, "Public Health as Social Justice," Dan Beauchamp makes this stunning point:

"The critical barrier to dramatic reduction in death and disability is a social ethic that unfairly protects the most numerous or the most powerful from the burdens of prevention. This is the issue of justice."

In other words

** Injustice stems from our failure to prevent harm, our failure to take precautionary action.

** Failure to prevent harm occurs because prevention might inconvenience some powerful group (powerful with votes, or powerful with money). Public health -- like environmental justice -- calls us to take collective action to overcome the resistance of the powerful.

So that's why public health matters, and that's what it's about.


[1] In his 1850 Report [to the Massachusetts Legislature] of a General Plan for the Promotion of Public and Personal Health, Lemuel Shattuck defined public health this way:

"The condition of perfect public health requires such laws and regulations, as will secure to man associated in society, the same sanitary enjoyments that he would have as an isolated individual; and as will protect him from injury from any influences connected with his locality, his dwelling-house, his occupation, or those of his associates or neighbors, or from any other social causes."

Mr. Shattuck went on to highlight the main idea that has motivated and undergirded public health from 1850 to the present day: prevention: "We believe that the conditions of perfect health, either public or personal, are seldom or never attained, though attainable; -- that the everage length of human life may be very much extended; and its physical power greatly augmented; -- that in every year, within this Commonwealth [of Massachusetts], thousands of lives are lost which might have been saved; -- that tens of thousands of cases of sickness occur, which might have been prevented; -- that a vast amount of unnecessarily impaired health, and physical debility exists among those not actually confined by sickness; -- that these preventable evils require an enormous expenditure and loss of money, and impose upon the people unnumbered and immeasurable calamities, pecuniary, social, physical, mental, and moral, which might be avoided; -- the means exist, within our reach, for their mitigation or removal; -- and that measures for prevention will effect infinitely more, than remedies for the cure of disease." (pg. 10)

[2] C.E.A. Winslow, "The untilled field of public health," Modern Medicine Vol. 2 (1920), pgs. 183-191.