by revere, cross-posted at Effect Measure

A couple of ideas are floating around in the comment threads as part of an initial conversation about public health. I’m not surprised they seem to be on different topics and have the feel of talking past each other.  We are not used to discussing basic assumptions and have an immediate tendency to talk about what we know, what interests us particularly, what bothers us most or what is our particular preoccupation.  Many of those things turn out to be really important for public health and there are plenty of reasons for talking about them.

Annie, for example, is frustrated with other medical and public health professionals.  From appearances she is herself a dedicated public health professional and feels alienated from her peers.  Like other professions we have become guild-like, with all the usual tendencies to draw lines around what we do, lines that keep others out.  The Association of schools of Public Health is now promoting certification exams, a very bad idea in my view. Who should get certified? As commenter/economist floormaster squeeze observes, the community’s health is tightly tied to the general state of the society, both economically and socially.  By that definition there are a whole lot of people “engaged in public health” that don’t fall under the usual disciplinary titles and even more who do day to day work that contributes significantly to public health (like the RotoRooter guy or the water treatment plant operator or the cop on the beat). I’m not advocating expanding the definition of public health so far that virtually everyone falls under that heading, but I am suggesting we start to think hard about what could properly and usefully be brought under the ambit of public health and what should not.

For example, commenter rotatingmass (RM) remarks that a major change from the early days of modern public health is the inclusion within public health of access to care, its financing and its administration.  It is not a minor point.  Health services has become the preoccupation, resource hog and motor of much going under the name of public health today, and RM wonders if public health might not benefit from a divorce.  Question: what would that leave, what should be included that isn’t, what should be further amputated from public health? Maybe it would be useful to shuffle some things like bioterrorism response into public safety, keeping pandemic response for public health and acquiring meteorology.  Maybe not.  There are trade-offs here and we should be discussing them openly and honestly, including the pros and cons.

As usual, DemFromCT makes an important point.  We need new models.  But a model of what?  New models aren’t likely to come only (or at all?) from within public health.  We are inviting another kind of engagement in public health, the engagement of the hivemind.  If you don’t think of yourself as a public health expert, you can still help think this through. Our thinking in public health has become ossified.  Don’t worry if you think your ideas are stupid or off topic. On the basis of blogging daily for four years (during which time I’ve had plenty of practice saying stupid and off-topic things), I’ll predict most of the ideas that will wind up in the comments will be at least uninteresting or off topic.  Try again. But some of them won’t be.  It’s the job of all of us to find the diamonds in the rough, separate them from the dust, cut some gleaming facets and polish the result.  A little bit at a time.

What, then, is this project we call “public health”?  One useful formulation of public policy is that it is what the community chooses to do for each other.  By that definition, if, as MRK expressed it in his comment, your objective is only to look out for yourself, then you aren’t engaged in public health (although someone else may be, on your behalf). But maybe it’s not a good definition. What would be a better one?

A lot of people have no patience for this kind of abstraction.  My advice is to come back later when we might have some of this sorted out.  But the difference between a conception of the bottom line that it is everyone for himself and one that says there are some things we will agree to do for each other is not trivial and deserves to be discussed, along with still other radically different views.  I strongly disagree with MRK on this (as on many other things), but I like very much that he decides to go directly for the jugular, what he sees as the core of the question.

What do you see as the core of the question? And what question?

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