Map of life expectancy at birth from Global Education Project.

Monday, November 06, 2006

The politics of public health

The vast multitudes who attend APHA -- and I mean that sincerely, it's a huge convention, with something like 15,000 registrants -- are not exactly a revolutionary vanguard. They are state and federal bureaucrats (by now, more than half of them appointed or hired by Republican governors or the Emperor of Mespotamia); scientists in many disciplines, most of whom study narrow problems with no obvious political content (such as my own work on physician-patient communication, although there might be some politics in there after all); practicing physicians and other kinds of health care providers; health educators who teach people how to eat or exercise or take their pills; and yes, a few community organizers and public health outreach workers and advocates whose work is to a greater or lesser extent bound up with social change or compels them to activism.

Nevertheless, since John Snow took the handle off the Broad St. pump in 1854 (or maybe he didn't, but it's the idea that counts), thereby ending a cholera outbreak, the public health community has been reality based. And as we all know, reality has a liberal bias. In the first place, fundamentally, there is a strong gradient in health status and life expectancy associated with the construct called socioeconomic status. People with more money, more education, higher social status, more authority in the workplace, live longer, healthier lives. Ergo, reducing social inequality means a healthier population. And no, it doesn't happen at the cost of worse health for the rich. There are fewer of them to begin with, and they have more than enough. The greater equality of European countries compared to the U.S. is one reason why their populations are healthier.

Second, public health depends on public goods. These include clean air, clean water, clean food supply, open access to information, safe neighborhoods, well educated children, control of infectious diseases even among people who can't pay for medical care on their own, and a whole lot more than markets don't supply, and powerful interests such as corporations and rich folks who don't want to pay taxes don't want us to have.

Third, moral sanctimony founders on the rock of truth. Your "moral values" may lead you to demand abstinence-only sex education, but the truth is that it doesn't cause abstinence, doesn't prevent sexually transmitted infections, and doesn't prevent unintended pregnancy. Moral condemnation of homosexuality doesn't do anything to cause people not to be homosexual or not to engage in homosexual behavior (just ask Ted Haggard) but it does cause young people to experience shame and anguish, to be shunned by their peers, sometimes to kill themselves, sometimes to develop substance abuse problems; and it makes it impossible to provide people with information and resources to stay healthy. Declaring that obesity or abstinence from tobacco are matters of personal responsibility doesn't fix the toxic food environment or the trillions spent by corporations to manipulate us into eating and inhaling poison.

And, obviously, war is bad for children and other living things.

So, that reality base forces public health researchers and practitioners to favor one party over the other in the current U.S. political scene. There's just no getting away from it. Will the prospects for public health change dramatically if one party rule ends in the United States? No. But it is possible that in the years ahead, they'll start to look up a little bit. Maybe we'll even catch up with Cuba, in a few decades.

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