Core values of public health

In 2010 I spoke on "Equitable public health engagement" in a session targeting health problems of First Nations at the Centennial Conference of the Canadian Public Health Association in Toronto. Here is the text of my remarks.  I left out the paragraph on Osler's Aequanimitas to save a few moments and allow a little more discussion time. Otherwise I said pretty much what's written here.  Is it worth while to clean up this text, generalize beyond First Nations,  and publish it somewhere?

 Core Values of Public Health

My favorite image signifying the meaning of public health is a picture of rescuers at the scene of an earthquake, a life-threatening disaster. People, usually strangers, do all they can to help other people whose lives are in danger. They tear at the rubble with their bare hands in case there may be somebody alive buried beneath it. It is a vivid demonstration that we are hard-wired with something akin to an instinct to come to the aid of others who need help.

That’s what public health is about: coming to the aid of people who need help. Nowadays the aid is mostly unobtrusive and those who benefit are unaware that they needed and have received help. Public health practice saves countless lives by ensuring that water and food are safe, infants are immunized against communicable diseases, and other routine public health measures are rigorously followed.  Dramatic life-saving actions are very rarely necessary in public health practice but we are ready to activate these at short notice, for instance in the event of an outbreak of a highly contagious disease caused by an imported case of haemorrhagic fever – perhaps the nearest public health emergency comparable in dramatic impact to an earthquake measuring 6 or more on the Richter scale.

I spent much time and effort compiling a Dictionary of Public Health, defining the concepts, methods, and procedures that collectively comprise the science, practice and art of public health. The purpose of public health can be summed up in the phrase: coming to the aid of people who need help. That may mean all people everywhere, as with safe drinking water (residents on many reservations for aboriginal Canadians do not have this necessity for healthy life). Or it may mean any other population subgroup, some easily identified and easily reached, others vaguely delineated and hard to reach, some elusive, and needing urgent help. Today we are considering one group, First Nations, especially children and youth. Other groups who often need help are single-parent mother-led families, particularly their infants and children; isolated elderly people living alone in a former family home; street people with mental disorders; prison inmates. Only rarely are any of these groups adequately represented at strategic pubic health planning discussions.

At meetings where environmental problems are being considered, some groups may be over-represented. Industrialists, mine owners, developers, and their spokesmen, sometimes speak loudly, act aggressively, drown out or try to suppress dissent. In some countries they have been known to silence dissent or opposition e.g. to oil exploration and mining, by brutal means, up to and including murder.

In coming to the aid of people who need help, public health professional workers don’t distinguish one group or class of people from another. We don’t discriminate on the basis of age, sex, race, income, occupation or any other identifying characteristic. That’s what ‘equity’ means: all are considered equally. There is no such thing as some being more equal than others, like the pigs in George Orwell’s Animal Farm.

What are the philosophical foundations of public health? Consider its core values, the moral basis of public health. The 1940s UK social administrator Geoffrey Vickers described the historical progress of public health as ‘redefining the unacceptable.’ This is a core value of public health. The pioneers of the sanitary revolution in the late 19^th and early 20^th century knew enough about the causes of disease to recognize that it was unacceptable to cough and spit indiscriminately, to prepare food in a filthy kitchen, to provide polluted municipal water supplies, to allow owners of mines and factories to employ little children. By the 1990s public health workers and many others knew it was unacceptable to smoke without permission in somebody else’s home, on an airplane or in a crowded elevator or bus; to drive a car while impaired by alcohol or drugs, to carry infant and child passengers in a car without correctly fitted safety seat restraints.  Soon I hope it will be unacceptable for any person or corporation to pollute the land, sea, or air, or to emit combusted carbon products into the atmosphere. It is unacceptable to ignore distress signals like suicide of young native people, nutritional deficiency diseases among isolated old people, drug and substance abuse by homeless street people, and other less obvious signs of the persisting inequities in modern Canadian society.

In public health practice we are proactive, not reactive, seeking and solving potential problems, not just waiting for problems to happen. That’s why we have immunization programs to prevent outbreaks of polio, measles, diphtheria and the like, and why these programs should be mandatory. It’s why we purify municipal water supplies, close unhygienic restaurants, why we campaign against tobacco smoking and substance abuse. It is why we have sex education classes in school, and family planning clinics accessible to teen-age girls whether or not their parents approve or know that their daughters are coming to the clinic; and why we oppose patriarchal and authoritarian attempts to restrict access by school girls to education about sex and sexuality and access to contraception (and if this fails and an undesirable pregnancy occurs, access to safe, legal abortion).

Sometimes we are not proactive enough. There are subgroups in every population who need our help but do not seek it for one reason or another. Some equate public health services with authority figures that for one reason or another they dislike, are averse to, or distrust. Some marginalized people feel stigmatized for instance by their appearance or their shabby clothing, and avoid waiting rooms in clinics because of shame or reluctance to be seen by and, they fear, overtly or covertly criticized by others they might encounter there. Some have a problem understanding the language used by public health professionals. E is for extra effort as well as for equity, to ensure that these people receive public health services of the best possible quality.

An important consideration in equitable public health engagement is the baggage that the public health worker brings to her or his interaction with individuals and groups that need help. Ideally public health workers should be impartial, objective. They should always be ready to provide the only therapy administered by ear – words of comfort.

          They should possess what William Osler described and discussed in Aequanimitas, the capacity to evaluate and resolve complex problems without becoming emotionally involved with the people who are the victims of the problem (or others who may be causing them). Yet the role and function of the public health professional includes being an advocate for the persons or groups afflicted with the problem. Striking a balance between impartiality and advocacy can be very difficult!

Among Canada’s attractive features is multiculturalism. It has some potentially harmful features; but its strengths and inherent goodness outweigh these. I mention it only to offer a cautionary word. The cultural roots of a public health professional must never influence her or his interaction with clients or population groups who happen to have different cultural backgrounds. First and foremost we are Canadians. We may be hyphenated Canadians, but the qualities embodied in that hyphenated word are irrelevant in our professional interactions. This is a necessary statement, but it is not sufficient. Public health professionals have a responsibility to know and to understand enough about the culture of the population groups with whom they work so that they do no harm by inappropriate kinds of interaction.

Inequitable public health engagement is commonplace, even in nations that pride themselves on their equity, their fairness. In Canada we proclaim our tolerance and the excellence of our democracy but our body politic is so manifestly, so blatantly inequitable, the playing-field so obviously uneven, that it amazes me when our political representatives, our elected “leaders” boast about the excellence of all things Canadian, implying that it’s so perfect it can’t be improved.

In March 2010, disturbing news reports emerged about the shockingly high incidence and prevalence of tuberculosis among First Nations and Inuit Canadians – among the highest in the world. The flames of infection with tuberculosis are fanned by deplorable living conditions, by poverty, overcrowding, poor nutrition, and by ignorance, alcohol and substance abuse. If we needed any further warning signals of inequitable public health engagement with these underprivileged members of the Canadian population, the morbidity and mortality statistics for tuberculosis have provided them! This is more than a public health issue; it is a public policy issue. In 2008, prime minister Stephen Harper issued an apology on behalf of Canada for past injustices associated with the residential schools policy perpetrated against the descendants of the original inhabitants of Canada. As Barack Obama said in another context, that apology was “just words.” To have any meaning, the words must be matched with action, and no action has been forthcoming to remediate the deplorable living conditions of the descendants from the original inhabitants of our country. As the Nobel Peace Laureate Amartya Sen pointed out in The Idea of Justice, social justice is a powerful determinant of health. It follows that victims of social injustice will be unhealthy; the morbidity and mortality statistics of tuberculosis eloquently and accusingly illustrate this harsh reality, as do many other health indicators. Canadian public health has been an abject failure in not advocating effectively to correct this injustice. The next generation of public health leaders must do better than my generation to correct these inequities.