by revere, cross-posted at Effect Measure

I’m (more than) pleased to say the public health conversation is starting. I assume it was already going on but not where we could all hear what others were saying. So let me continue by responding to a point raised at The Pump Handle (TPH) that was also the subject of offline discussion from someone who read the post. Liz and Catherine (at TPH) made special reference to this comment from me:


“If I am an ordinary person, I don’t want to have to think about public health. I want it to work well but in the background, like the water system.”

Each had a slightly different take on it, as did my offline discussion. First, Liz:

Part of the problem may be that people don’t have to think about things like clean water, so they take them for granted and don’t factor them into their political decisions. The anti-big-government tactics gain traction because people forget that government provides many important services, from sanitation to drug review, that are extremely valuable and require lots of personnel and infrastructure.This is why I was pleased when the Center for American Progress started running ads reminding people that we have government to thank for clean water, Social Security, and oversight of drug and toy safety. I don’t know whether CAP has continued to push that idea, which was part of an effort to rally people behind the “progressive label, but it’s a valuable thing for them and others to be doing.

It’s an uphill and ongoing struggle to remind people to be grateful for the easy-to-overlook public health services they have, let alone rally support to put more funding into infrastructure that they didn’t realize was broken.


This is quite different than the point I was making. I assumed that not thinking about public health was a normal and rational thing for most people (we in public health naturally like to think about it, but that’s an obvious selection bias). Liz identifies what I considered rational to be a problem to be solved. People take public health for granted, or, more generally, take for granted the benefits of having a government do things we can’t do for ourselves. It is an important point. If the Republicans want to give me a $600 tax rebate because “people know better than government how to spend their money,” someone needs to say that I can’tbuy better police and fire protection or a safe food and water supply or the many other things that require my $600 to be put together with my neighbor’s $600 and her neighbor’s $600, etc.

That’s true. Does it mean that we want to think about public health, though? I don’t want to think about bridge safety, I just want safe bridges. Both Liz and Catherine assume we can’t have safe bridges or safe water if people don’t think about them. This may well be true, although I consider it an empirical question. I doubt it is a general principle, because very few people think about the electrical grid (until it doesn’t work) and yet we have an electrical grid. It isn’t a government entity, either, although it’s part of the community infrastructure. Catherine seems to go further and identify the failure to think about public health as almost a moral failing:

Sometimes we have to think about the things that we want to pass off to others to think about. The answer isn’t in thinking less, engaging less, it is in the exact opposite.We have been disengaging far too much. Our busy, stressful, lives are not to blame they are our excuse. We do not do, we do not look at, we do not engage ourselves in what is unpleasant.

We leave that to others.


Catherine ends by saying we need to put the public back in public health, meaning in this context I assume, more public participation and the assumption of responsibility of each of us for public health in our community.

A different take came from the offline conversation. The problem isn’t that people don’t care about public health. It’s that they care too much about too many different things: mercury in vaccines, substance abuse, suicide, obesity, alcohol, etc. The “public” in public health is a chaotic world of advocates, not activists, each passionate about his or her own area, neither strategic nor caring that others think other things are “the most important problem in public health.” Advocates for their areas of interest, not activists for public health.

Three different takes on my claim that ordinary people don’t want to think about public health: they don’t, and that’s too bad; they don’t, and that’s a failure to take responsibility; they do, and that’s too bad. All three views were more nuanced than this, but my main point is that four people who think a lot about public health didn’t see a major but usually undiscussed point in the same way. Because it really does matter for what we do whether average people are genuinely interested in public health and in what way. It matters for what we do, how we think about ourselves and our chances of success. When we do talk about it, we don’t seem to agree.

That was just one aspect of the comments to yesterday’s post. There are other interesting thoughts in the comments and I am hoping we’ll start to discuss them, not just in terms of a list of things to do but in terms of underlying assumptions we make about what we do and why. Maybe we’ll find that after subjecting them to a searching examination we were justified and can move on. But I suspect we will find that we haven’t bothered to think hard enough about them.

Like whether people do or should care about public health.