Blowing Smoke

For reasons I will not elucidate, I've been engaged in a thought experiment. Suppose that instead of writing a blog that a few people read when they are home sick and there's nothing on TV -- i.e., whenever they are home sick -- I had the opportunity, the privilege, and the responsibility of being the main conduit of information about public health and health care for a large community of politically active people. It would be my choices of subject matter and my interpretive slant that defined public health and the politics of public health for a million or more engaged readers.

How would I interpret my responsibility? How would I apportion the subject matter of my posts? What essential issues and ways of thinking about issues would I guide my readers to consider? There is no specific right answer to this challenge, but I consider it ethically compelling and I would think hard about doing the job in a way that served the common interest.

My answers are still developing, but here's what strikes me initially.

First, I would take a global perspective. In the scenario I am writing principally for a U.S. audience with a foremost interest in U.S. policy and politics, so I would emphasize issues of particular concern in the U.S. more than the 5% of the world's population we represent. But I would nevertheless work very hard to put our problems in context and to make time for problems that don't affect us in a direct and obvious way as well. That's both because my ethical perspective is that of a citizen of the world, a human first and an American second; and also because we are in fact interdependent and what happens everywhere does ultimately affect our own well being.

Second, I would organize all of my around the social determinants of health. The usual way to think about the determinants of health is to consider the social and economic environment, the physical environment, and people's individual characteristics and behaviors. But it is essential to recognize that these interact. People who are socially and economically disadvantaged generally experience less healthful physical environments, and have less healthful personal behaviors, not because they are irresponsible but because our behavioral options and choices are powerfully shaped by external influences. Health is strongly determined by social status and the health of whole societies is damaged by inequality. Public health is fundamentally about equity and justice: the most powerful way to improve the health status and life expectancy of populations is to reduce inequality and improve the circumstances of the disadvantaged.

So what diseases and risk factors would I tend to discuss the most? It depends partly on contingencies, of course, but you would, first of all, see a fair amount about the great infectious scourges of humanity -- HIV, TB, malaria, diarrheal diseases of children (mostly from unsafe water), pneumonia (strongly associated with the compromised immune systems of undernourished and chronically ill children). And there are numerous less prevalent but still very important infectious and parasitic diseases that place a huge burden on many populations such as leishmaniasis, river blindness, guinea worm, etc. So I would discuss those.

These are of considerably less direct importance in the U.S., however, so I would also emphasize our challenges at home. Tobacco control is still very high on the list, but obesity, physical inactivity and diet are right up there. If we don't act with a real sense of urgency, diabetes is going to overwhelm our health care system, and quite imminently. By the way, there is a strong social class component to both of these problems; and they are also very much driven by corporate greed and irresponsibility.

Other major issues for the U.S. include unintentional injury -- much of it motor vehicle related, but we still have important areas of occupational safety and health, and household safety, to address. Again, these are problems with a strong political component. Violence is also a huge problem, again with a class and caste differential but also with a gender dimension. Most violence in our society is hidden within families.

If you are particularly worried about children, remember that diabetes begins in childhood, tobacco addiction begins in adolescence, that millions of children in this country are victims or violence or witnesses to violence, and that the most likely way for a young person to die is in a car crash.

Universal access to affordable, quality health care is important, so of course I would discuss that, in its proper place and context. Health care is not in fact the most important determinant of population health, but it is more important than it used to be and anyway, this is a fundamental issue of justice. But it comes after truly basic needs -- safe and healthy housing, adequate and healthy diet, nurturing family and community, educational opportunity and the opportunity for meaningful and remunerative employment. By the way a rational drug control policy and emptying our prisons of non-violent drug offenders is part of that.

Global and local physical environments, free of dangerous human caused pollution and pathogens would be in my mix. Oh yeah, antibiotic resistance. Food safety. All sorts of smaller or highly specific issues that might come along. I'd try to mix it up, but keep it all within the framework of social justice, because that's where the politics of public health are rooted.

I think if I could pull that off I would have honored my privilege, opportunity and responsibility.