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Friday Dec 21, 2018

Have We Failed to 'Promote the General Welfare' of People?

Sometimes in life you get lucky. Sometimes your master's in public health program offers intensive classes in Barcelona so you can take two in a week while eating paella and gelato and hanging out in massive cathedrals. That's my kind of luck.

[copy of Constitution with American flag in background]

Here, in my fourth installment of posts related to my M.P.H. classes, I will talk about the structural determinants of health.

Now, you may be wondering why I say "structural" instead of social or socioeconomic. Basically, the term structural does two things for me. First, it highlights the fact that we ought to be interested in the overall, nonindividual factors that affect the health of groups of people as well as individuals. Yes, poverty affects the health of the individual, but if you have societal or political structures that enforce poverty geographically or on a class basis, you've got a bigger problem. Second, "structural" is a lot easier to say than "political, cultural, economic and social."

In part three of this series, I shared my working definition of public health: "Whenever a pattern of morbidity or mortality emerges, any contributing factor is within the scope of public health."

The class I took on structural determinants served primarily to broaden this scope to include federal economic policy. Now, I need to be honest here in that this class is the least applicable to the individual patient room, but it is just so interesting that I had to share what I learned. I welcome alternative interpretations of the information conveyed in this largely opinion-based class.

First, we defined health. Notably, the instructor encouraged us to consider health to be more than merely the absence of disease, but rather "a state of complete mental and physical and social well-being, not only of the individual but also of the community." This serves to broaden our definition of public health even more. Thus, if you're sitting at a family supper and you are asked why those of us interested in public health are talking about things like violence involving guns or climate change or the overall economic plan of our country, I encourage you to remember this definition.

Next, we identified all the bits and pieces of society that affect this expanded definition of health. They include, but are not limited to, the following elements. In order to be fully healthy, people need

  • the belief that they have power in their political system -- and thus in the structures and society that make up their environment -- including the ability to vote and have meaningful interaction with the political structure;
  • economic and social security that allows them to feel secure about employment or retirement;
  • a good, safe and healthy environment for working, living and raising children that includes access to health care and opportunity;
  • effective, accessible and comfortable (read: trustworthy and nontraumatizing) medical services;
  • effective protection against communicable disease, in terms of both basic knowledge and public alert systems;
  • public understanding of and access to healthy, safe food;
  • an understanding and appreciation of safe sex and good reproductive health, with an emphasis on avoiding STDs and undesired pregnancy;
  • decreased exposure to tobacco and drugs;
  • access to and positive norms surrounding physical activity -- ideally, 30 minutes per day; and
  • a general feeling of solidarity and purpose -- something to think about beyond oneself.

As you might expect, the class created a list of the types of policies that, given our expanded responsibility, would fall under the purview of public health. Such policies would

  • encourage participation in society, including by voting or exercising social power, especially among underrepresented groups;
  • affect economic and social determinants (read: jobs), through means such as social security, welfare state and full employment policies;
  • reduce inequalities;
  • maximize solidarity among a nation's diverse groups;
  • create healthier working environments;
  • focus on environmental and consumer protection, including climate change;(www.thelancet.com)
  • offer secure and favorable conditions during childhood and adolescence; and finally
  • address health care interventions that prevent disease, such as food safety programs.

Some of these policies obviously lend themselves easily to legislation, and some seem more reliant on social and behavioral norms, but I argue that although sometimes laws reflect the culture of a place, at other times they help create the culture. This, of course, is where we start talking about built environments that offer ease of physical activity, neighborhood policing strategies that create safe neighborhoods, voting laws that allow the citizenry to feel they are part of the political structure, and tobacco laws that regulate advertising and additives.

This list should make you, as someone interested in public health, feel empowered to think more broadly and more ambitiously than before. If anyone argues with you, remind them, as described in the U.S. Constitution, that our national government is meant to "establish justice, ensure domestic tranquility, provide for the common defense, promote the general welfare, and secure the blessings of liberty to ourselves and our posterity." Feel free to emphasize "promote the general welfare" as much as you'd like.

In its focus on economic policy, the class on structural determinants tried to show that neoliberalism (the economic theory that minimizes government involvement, choosing to trust instead in the good of the free market) has failed the constitutional mandate to promote the general welfare of the people. I don't want to try to make that argument here. I know that some people think that the market is not free enough, and others think the free market does OK on goods and services but gets wonky as soon as the financial sector gets involved with its credit default swaps and derivatives.

What I want you to know is that if society is set up in such a way that people feel insecure about their job, their retirement or their station, or if they feel powerless or without equal opportunity, it will not be healthy. The people may not have a specific disease or illness, but it's certain that they also will not have a maximized state of physical and mental well-being.

I think we can do better than that. In no way am I arguing that we should try to ensure equal end points, but I am arguing that we should at least try to ensure equal opportunity.

The real point of this class was to show that equal opportunity is tied part and parcel to individual and community welfare, and thus, the public health sector should have something to say about it.

Maybe equal opportunity means universal health care that gives everyone access to the same quality health care throughout their lifetime. Perhaps it is universal funding for college. Perhaps it is less regulation on banks. I don't know.

The point here is that as people interested in the health of the public, all of this is our lane. You should feel empowered to do your research and share your opinions, whether on national health policy or on gun safety or on the economic structures of our nation.

Be respectful, be knowledgeable, and always stay in your lane. Just know that, as someone swinging with the full scope of public health, everything is your lane.

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 11:44AM Dec 21, 2018 by Stewart Decker, M.D.

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