Shifting the Framework for Public Health

By Solange Gould

To enact the structural and policy changes to realize our radical vision for public health, we need to get really clear on what public health is, does, and can do.

In 2020, public health became a catchphrase in popular discourse. In news media surrounding the COVID-19 pandemic, as well as the uprisings against policing and in defense of Black lives, the term was often deployed to spotlight how various systemic crises cause harm and violence. We rightly asserted that “Racism is a public health crisis” and demanded that our decision-makers “Defund the police, invest in health”.

This was an important first step in shifting the narrative. Events of the past year catalyzed a growing recognition that nearly every aspect of our lives intersects with public health— and that health and social justice are inextricably linked. Through the lens of COVID-19, these intersections were made starkly visible: our inequitable social and structural conditions both produce and are produced by health, and our collective wellbeing is inherently interdependent.

Now, in the second month of 2021, we are in a moment of great possibility and risk. The Biden-Harris administration has issued a raft of executive orders that reverse some of the Trump damage, and go further in prioritizing public health, equity, racial justice, and climate change. We must continue to seize upon this opportunity to push this administration, and to put forward ever more visionary and transformative solutions to address the enormous challenges we face. We need a vast infusion of mandates, resources, workforce, and training to build a public health system that truly dismantles systems of harm and creates collective health. And we need powerful and visionary narratives to drive that structural and material transformation.

In order to enact the structural and policy changes necessary to realize a radical vision of public health, we must clarify what public health is and does, as well as what it can do.

What is public health?

This includes housing, education, living wages, good jobs, food, clean air, water, soil, a stable climate, and belonging. All of these systems and factors are necessary for health, and structural racism shapes each of them. This is precisely why COVID-19 has hit Black, Latinx, and Indigenous communities the hardest, and why dismantling structural and institutional racism must be at the core of any work toward health equity.

We must build a public health system that neither returns us to the pre-pandemic status quo, nor re-inscribes the broken systems that got us here. Public health needs to be resourced, authorized, and equipped with new capacities and tools to prevent and respond to the multiple concurrent crises we are facing. Our strategies can cultivate collective health by addressing root causes, dismantling systems of oppression, exclusion, and harm, and building systems and economies that support health for every person.

Critically, this new public health infrastructure must be grounded in an analysis and practice of racial, gender, and economic justice, fueled by collective action, and led by and alongside those who are most impacted by structural inequity and oppression.

The power of public health narratives

Dominant narratives about public health are narrowly focused on health care and individual behaviors, rather than on the policies, systems, culture, and environments that support collective wellbeing. As a result, popular understandings of public health tend to be myopic, with the onus of responsibility placed on the individual, rather than the collective. Budgets, policies, government infrastructure, and systems then flow from and reflect this.

Public health narratives have shifted over time. The field’s origin story dates back to the mid-1800s, when doctors joined with city planners and labor organizers to address conditions in tenements and factories. The field then changed dramatically in the 1860s with Louis Pasteur’s discovery of the relationship between germs and disease, accompanied by a narrative shift that contributed to a popular notion of health overdetermined by individual germs residing in individual bodies directed by individual behaviors. Individual responsibility quickly became the locus of public health interventions, with services and directives aimed at people’s behaviors forming the main public health narrative: don’t smoke, eat well, practice safe sex, and get exercise.

Over the past 20+ years, due to the dedicated work of public health advocates and social justice movements, the narrative about public health has begun to shift to address inequities in living and social conditions, and more recently, power imbalances and structural racism. The work of this new public health is intersectional, cross-sector, systems-level, and aims not only to provide care and services for those who are sick or suffering, but to prevent harms in the first place.

Yet, despite this goal, our field has continued to experience a devastating gutting of resources. According to a 2019 Trust for America’s Health report, health care spending grew by 52% in the past decade, while the budgets of local health departments shrank by as much as 24%. Today, public health claims just three cents of every health dollar spent in the country. Meanwhile, free market capitalism has long exploited public crises to quietly usher in policies that erode our public health systems and increase privatization and profit. We’ve seen this in full force during COVID-19.

These decades of divestment have weakened our public health system’s most basic capabilities. The COVID-19 pandemic has shown us that the biggest driver of the virus is neither the “germ” nor the individual’s behavioral choices, but the material conditions, policies, and systems that constrain all “choices” (i.e., affordable and stable housing, paid leave, worker protections and rights, immigration status, and incarceration), which are in turn driven and patterned by the forces of structural racism, capitalism, and power imbalances that perpetuate deep inequities.

A peculiar combination of popular public health narratives have blocked public health from even its most basic and traditional function of disease prevention over the past year. And the same narratives of individualism and personal responsibility that structure popular discourse on public health also uphold and reinforce racism, xenophobia, capitalism, policing, incarceration, anti-immigration policies, and other systems of harm. Moreover, concerted misinformation campaigns like climate denial, COVID-19 denial, and other wild conspiracy theories have forced the field to focus on limiting the spread of disinformation and defending basic disease prevention, rather than transforming the systems necessary for health equity.

A transformative vision for public health

The Biden-Harris administration has made some positive moves with recent executive orders to direct investments in COVID-19 containment and vaccinations, to advance health equity, to address institutionalized racism across the Federal government, and integrate public health, racial justice, and climate change in regulatory decisions.

Now we in the public health community and alongside our movement allies must demand a substantial and transformational investment in our public health system’s capacity to work on racial and health equity, health in all policies, climate change, and engage with community power building organizations to advance health and social justice goals.

Let’s leverage transformative frameworks for a transformed public health

To do that, we need to clearly and consistently communicate a visionary narrative about the function and value of public health. And a transformative public health narrative —focused on a collective and intersectional notion of what supports health, and rooted in the knowledge and work of communities most impacted by inequity —will in turn inform the budgets, resources, programs, training, and workforces that will be deployed to achieve that vision. Together, we must transform how we think about, engage in, and advance the work of public health. Our very survival depends on it.

Resources and framing tools to shift the public health narrative

We all have a powerful role to play in re-imagining and sharing a transformed narrative of public health, grounded in a vision of a future where all have what they need to thrive. Here are some additional resources to deepen your thinking around public health narratives, and to help shift the framework toward collective health:

  • Join Public Health Awakened, our national network of public health practitioners and allies organizing for health, equity, and justice. Share social justice campaign actions with the Public Health Awakened network to engage the national health equity community.
  • You can also join Public Health Awakened’s First 100 Days Workgroup to put pressure on the Biden-Harris administration to take bold action to advance social justice and health equity. Email sari@humanimpact.org to get involved.

Solange Gould is Co-Director at Human Impact Partners. Along with Lili Farhang, she’s responsible for advancing the mission and strategic direction of the organization. She has been in public health practice for over 20 years, advancing progressive policy and systems change to improve health, equity, and sustainability with government partners, advocates and organizers, and communities most impacted.

📌 Did you know? Human Impact Partners provides health equity capacity building to public health organizations. Contact us to learn more about our offerings at info[at]humanimpact.org.

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