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Thursday Nov 29, 2018

Focus on Decision-makers to Improve Public Health

To recap, as I pursue a master's degree in public health during my first year as an attending, I am distilling my M.P.H. classes into digestible, "useful to the family medicine doc" bits. Working on the degree is difficult, but oh-so-educational, and I'm seeing that family doctors are perhaps the physicians best positioned to enact public health changes in our communities.

[are you talking to the right people on bulletin board]

Today, I bring you part three, in which we discuss campaigning and organizing.

I really appreciated the course that covered this because it made me appreciate the work and dedication it takes to be a community organizer. It also came at a time when I was struggling with how to address issues related to the social determinants of health that I identified with my patients.

We have been trained to avoid ordering a test unless it is going to change how we treat our patients, and this mantra works well for things like CT scans and daily labs, but I had felt hamstrung by a lack of resources when asking about hunger, poverty or homelessness. Some health care organizations have social workers or lawyers on staff (I recommend both), but most do not. This class helped me clarify the best ways to help my patients collectively.

(FYI, the AAFP has a fabulous tool capable of identifying social resources in your area and printing the details from the exam room.)

Let's start by defining our terms.

Campaigning means trying to influence the behavior of an individual or group of people. The purpose is to get them to think or act in a way they would not traditionally think or act.

Organizing is coordinating a group of people to be unified on a single issue. For example, politicians are not terribly worried about losing one vote, but they are worried about losing a large swath of voters.

The first and most important thing I learned from this class is that it takes a lot of work and time to become an organizer, so much so that it is its own career path. Thus, it is decidedly not for everyone. This, however, is why I am writing this post -- to identify the most pertinent points to the practicing family physician and flesh them out in a usable, applicable way.

First, I found it revealing to think about public health in terms of social justice, as opposed to market justice. Public health is not just about preventable infectious disease, but it is important to know that some people think this is the limit of its scope. Public health assumes a social justice perspective. This means that whenever a pattern of morbidity or mortality emerges, any contributing factor is within the scope of public health. I find this an empowering definition.

Second, we were taught to start with organizations. Organizations create campaigns and movements, not the other way around. If you are interested enough in a topic to consider building a campaign, try to start an organization first. If you do, try to make it as broad-based and diverse as possible. This widens your catchment so that more people, more votes and more opinions are represented. If you are not organizing, but instead participating, in a campaign, try to keep hold of at least a listserv, which can help you form an organization later.

Third, try official channels. Grassroots organizing and protesting is how you change opinions, not just laws -- and you want to change both.

Finally, and perhaps most importantly, for any issue there will be one or two key decision-makers. Those people will have a handful of influential people surrounding them. These two groups, the decision-makers and the advisers, are your targets, so focus on them. Don't waste time and resources on people who cannot affect the outcome or will not change their minds.

I think this is the most important lesson, because all of a sudden, I find myself calling on this little truth in unexpected places. The person who goes grocery shopping is the key decision-maker for what food is in the house. At city council meetings, there often is one swing vote, so you need to tailor your argument to that person and his or her interests. Regardless of why you support something, you need to address why the one key decision-maker should support it and hammer those points home with the appropriate person.

I have found myself coming back to two things from this class most frequently: There is health in all policy, and thus all policy is within the scope of public health; and it is imperative to find the decision-makers.

There is one more thing that I hope some of you have realized: It can be frustrating for those of us used to making decisions (that's what M.D. stands for, right?) to have to try to convince someone else to decide a certain way. Perhaps, if this proves frustrating enough, it is time for you to become that decision-maker.

Stewart Decker, M.D., is a family physician practicing in southern Oregon. He focuses on the intersection of public health and primary care.

Posted at 03:13PM Nov 29, 2018 by Stewart Decker, M.D.

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