Public Health? Forget It; Cosmic Issues Beckon
By Sally Satel
Sens. Bill Frist and Edward Kennedy are pushing the "Bioterrorism Preparedness Act of 2001" which spends most of its $3.2 billion on fortifying the public health system. With anthrax scares, the possibility of smallpox outbreaks, and the specter of other terrifying chemical or biological weapons used against us, Sens. Frist and Kennedy are clearly on the right track. But how prepared for "preparedness" is the public health profession? Not very if one looks to the American Public Health Association for guidance.
At its 129th annual meeting in October in Atlanta, the very backyard of the Centers for Disease Control and Prevention, the APHA compiled its "Guiding Principles for a Public Health Response to Terrorism." Put together just a month or so after Sept. 11, one would think the APHA blueprint would be all over the anthrax and smallpox threats with plans to update labs and improve massive response to an epidemic. Not exactly. Leading their 12-point plan:
1) "Address poverty, social injustice and health disparities that may contribute to the development of terrorism."
2) "Provide humanitarian assistance to [those] . . . directly or indirectly affected by terrorism."
3) "Promote nonviolent means of conflict resolution."
Not until point four does the APHA get to the heart of post-Sept. 11 public health needs, such as improving laboratory and surveillance systems. The guidelines go on mixing sober calls for availability of vaccines and data collection systems with appeals for the prevention of hate crimes, elimination of nuclear weapons and for "dialogue among peoples." Final tally: Five of the 12 guidelines are social engineering, with no reference to anything traditionally associated with public health.
This single document reveals a deep confusion within the APHA regarding its responsibility to the public and its profession. As the foremost organization of public health researchers and practitioners, the association's core mission should be to advance practical techniques for disease and injury prevention, enforce standards of scholarship, and educate policy makers. To be sure, much of the association's time and energy is spent doing just that. The executive director of the APHA, Mohammad Akhtar, appeared often on talk shows when the anthrax threat was most pressing, and did a good job talking about matters related to health. And another APHA document, with a policy action plans, focuses more directly on specific public health needs.
But the "guiding principles" of the association show preoccupation with broader national and international policy issues that are only tangentially related to public health. This year, for example, the APHA put forth policy resolutions against national missile defense, the war in Southwest Asia, and the General Agreement on Trade in Services.
The American College of Epidemiologists is similarly muddled. A smaller, more specialized group than the APHA, the college's Web site has been totally silent on bioterrorism since Sept. 11 -- a striking reticence in view of the fact that epidemiologists are arguably the most prominent players in tracking outbreaks of anthrax and other infections caused by biowarfare. Race politics, by contrast, is a large presence on the college's Web site. "The profession remains largely dominated by . . . men of European extraction," the college's leadership laments, and therefore the scientific realm is robbed "of perspectives and experiences that can advance the discipline."
This social justice agenda has become an increasingly prominent feature of the public health profession. A former dean of the Harvard School of Public Health, for example, proclaimed that "a school of public health is like a school of justice." The World Health Organization's definition of health, which goes beyond freedom from disease to a state of "complete social well-being," is widely endorsed by professors and practitioners alike. At the National Institutes of Health, the CDC, and health philanthropies, research on health disparities related to race, ethnicity and class -- and the policy implications thereof -- has expanded sharply.
These trends have prompted Ronald Bayer of Columbia University's School of Public Health to worry about "public health nihilism." Dr. Bayer refers to colleagues who believe that "public health officials can do little or nothing to change the prevailing patterns of morbidity and mortality in the absence of social change."
The upheaval of Sept. 11 poses a momentous opportunity for public health to reclaim its proper focus: to protect the population from disease. Even that function has suffered for many years: Back in 1988 the Institute of Medicine noted that the public health infrastructure was in "disarray." Mathematic Policy Research recently conducted a survey of directors of health departments in cities of 100,000 people or more, asking them to rate their capacity to fulfill essential functions. On average, the directors gave themselves a 35 on a scale of 100.
Eli Capiluoto, former dean of the University of Alabama School of Public Health, laid out a strategic plan in the Washington Post last month worth considering. It included mandatory licensing or certification system for public health professionals; none exist as they do for doctors, nurses and veterinarians. Local health departments, Mr. Capiluoto said, should undergo accreditation, just as health care organizations do.
Topics such as income inequality, oppression and others have their rightful place in political debates, but as targets of policy reform they are wildly inappropriate for public health. The profession has no expertise in solving broad problems of social injustice and, what's more, efforts in these directions divert public health from what it can and should do. Nowadays, protection from disease is nothing short of national defense.