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Library of Congress Cataloging-in-Publication Data
Bhattacharya, Dru, author.
Public health policy : issues, theories, and advocacy / Dhrubajyoti Bhattacharya. — First edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-118-16435-8 (pbk.), ISBN 978-1-118-22619-3 (pdf), ISBN 978-1-118-23952-0 (epub)
I. Title.
[DNLM: 1. Public Health Practice—United States. 2. Health Policy—United States.
3. Preventive Health Services—United States. WA 100
RA395.A3
362.10973—dc23
2013014313
A company of porcupines crowded themselves very close together one cold winter's day so as to profit by one another's warmth and so save themselves from being frozen to death. But soon they felt one another's quills, which induced them to separate again. And now, when the need for warmth brought them nearer together again, the second evil arose once more. So that they were driven backwards and forwards from one trouble to the other, until they had discovered a mean distance at which they could most tolerably exist.1
We are drawn to the field of public health from a myriad of personal and professional backgrounds, united in a common pursuit to help people live healthier lives. This diversity creates both opportunities and impediments to the development and implementation of interventions and what we may consider sound policy. Public health is inherently multidisciplinary, drawing from such health- and non-health-related disciplines as epidemiology, medicine, law, economics, politics, and ethics, to name a few.
Each of these fields understandably leans on its own assumptions, methodologies, and results to understand the nature and scope of problems. Epidemiologists concern themselves with the determinants and distribution of disease so as to target high-risk populations for interventions. Lawyers explain the legal parameters under which interventions can be implemented, or precluded, in a given population. Health economists contemplate a range of instruments to determine how best to maximize health benefits. Politicians set an agenda for bills that is based on their own existing priorities. Ethicists provide invaluable guidance on the underlying value and moral judgments that are made, wittingly or unwittingly, with every measure that we propose (or oppose).
The fundamental premise of this book is that health is a social construct. While this concept is central to the work of social epidemiologists, and has become increasingly acknowledged (perhaps even accepted) by many public health scholars and practitioners, its translation into conceptual frameworks in order to explore policymaking, implementation, evaluation, and advocacy remains inadequate, at best. This book hopes to fill this void. It is an introductory work, so students and practitioners who are eager to pursue further study are provided with additional sources of information in the chapter references. Encouraging that desire for continued learning is, in fact, one objective of this work, consistent with its quiet subtext that our work is a lifelong endeavor, reified by our willingness to engage others who may not share our personal or professional perspectives. Securing the public's health requires us to cooperate and collaborate in a fashion that at times may seem superfluous and at other times may give us pause, challenging us to confront our own assumptions and our expectations of others or perhaps of ourselves.
Ultimately, the journey is ours, woven through our education, research, practice, and advocacy, to improve the health and lives of our fellow citizens. It is a noble pursuit but one that is too easily forgotten, or lost, in the numbers we deal with. For most (if not all) of us, current trends are reason enough to inspire our calling to the health professions. Still, the inadequacy of public health funding and almost exclusive focus on health insurance in public discourse on health-related issues is a stern reminder that our public health story will not be an easy sell. I find the claim that public health is doing well when nobody notices it to be equally unhelpful by trivializing the explicit recognition of conditions that assure the health and well-being of the population. Far worse than an incoherent message is no message, so it should be no surprise when friends, family, or strangers give us blank looks when we mention public health. We have a story to tell, but part of our challenge is recognizing multiple plots and subplots, with a cast of characters as diverse as the practitioners who serve them.
On June 24, 2008, I had the privilege of attending the first congressional committee hearing on health disparities in over a decade. The number of attendees was limited and the line of hopefuls wrapped around the hallway, but I was fortunate enough to slip in, though I had to stand with my back up against the far wall. (I often share the video of the hearing with my students, who are amused by seeing me way in the back of the room.) The bill at issue, the Health Equity and Accountability Act of 2007, was introduced by Representative Hilda Solis (D-CA); it was being reviewed by the Health Subcommittee of the House Energy and Commerce Committee. Among those invited to present an opening statement was House Majority Whip James E. Clyburn (D-SC). A good politician (and health advocate for that matter) is a good storyteller, and Representative Clyburn was no exception. After reading from a statement, he departed from his prepared remarks to share a personal reflection:
I want to close my comments, Madam Vice Chair, by saying I am no healthcare expert, but I have seen enough of my friends, family, and most recently a beloved employee die from diseases that this bill seeks to address…. [M]y wife suffered from a heart attack and had a five vessel bypass surgery and on the day that I stood with her, as they were about to discharge her from the hospital, the doctor said something to the effect, I think we caught whatever it was in time. And then asked her, how does she feel. She said something is wrong. Now, this was the fourth day in the hospital, but she came, really, from a part of town that people just didn't think she would be having a heart attack. Yet, they finally decided to put the dye in, and when they did they found three 100 percent blockages and two 50s.
Now, I point this out to say to you, Madam Chair, that I came here today to testify on behalf of people who do not have good healthcare. I would not be celebrating with her our 47th anniversary today were it not for the fact that they took a second look. Not because of what her disease was, but because of who she was, and that is why we are here today.2
As a student, I was taught that public health was about populations, in large part to distinguish our field from the work of those in medicine and the other allied health professions who treat the individual patient. But Clyburn's testimony is a telling reminder that people constitute a population, not merely as enumerations of facts and trends of aggregate health burdens but as compelling narratives of the problems we face, individually and collectively. Although her physical symptoms did not indicate a problem, Clyburn's wife was insistent that she was feeling ill on the eve of her discharge. She was given further testing that revealed significant blockages in her arteries, a revelation to which Clyburn attributes her survival. That this testimony was given on the day of their forty-seventh wedding anniversary only heightened the sense of relief and concern, because they “would not be celebrating … today were it not for the fact that [the doctors] took a second look. Not because of what her disease was, but because of who she was.” Thus, the crux of the story was not that she got a second look, but that this follow-up was by and large the product of her status as the wife of a prominent member of Congress.
After years of studying and teaching health policy, I remain convinced that our pursuit of sound public policies for public health must embrace these narratives. Beyond their emotional appeal, they capture the experience of illness in its social context, beyond the physical debility that consumes our focus, embracing not simply how disease comes about but how we, as a society, respond to it. In this regard, the Institute of Medicine's definition of public health is often quoted: “what we, as a society, do collectively to assure the conditions for people to be healthy.”3 This assurance is a broad mandate that is at once vague and illuminating. It is vague in lacking precision about measuring concrete determinants of health and illuminating in the same vein because the social context of health requires that we refrain from taking such a myopic view of health. In the pages ahead, we embark on a journey to engage and understand public health problems from multiple angles, and to see the value of taking an approach that helps us identify novel points of intervention. At the end of the day, public health is about decision making, and that is a central theme of this book.
The framework set out in part 1 is intended, first, to enable readers to identify the myriad of issues that may be implicated by a given public health problem. With this knowledge, readers will be better equipped to prioritize evaluative criteria for comparing and contrasting the merits and shortcomings of competing interventions. The end goal, however, is always the same: to decide on a course of action. After acquiring the analytical framework (part 1), gaining experience in applying it to a range of public health problems (part 2), and practicing basic advocacy exercises in written media (part 3), the reader should have the confidence to tackle any public health policy issue.
In brief, part 1 (chapters 1 to 5) provides an overview of each framework component—law, ethics, economics, politics, and epidemiology and medicine—and its intersection with public health. Each of the chapters begins with an overview of lesson objectives, defines key terms and concepts, and is replete with examples of the precise way each component intersects with the field of public health. Each chapter also includes review questions and an interview that allows readers to hear from an expert in the field under discussion and get his or her real-world perspective on how that field relates to public health.
In part 2 (chapters 6 to 18), readers are exposed to thirteen illustrative case studies that use the framework built in the first part of the book. These case studies are not intended to be comprehensive but rather to facilitate discussion and illustrate how the five framework components, or disciplines, tie in to create, sustain, evaluate, or obstruct the development of public health policy. Toward that end, the case studies differ from one another in both content and scope. They examine such elements as comprehensive reports that argue both sides of an issue (but perhaps by drawing evidence from different disciplines), evaluations of national programs (for example, deciphering state trends in SCHIP enrollment and eligibility), prioritizations of competing health interventions in an attempt to standardize state practices to ameliorate existent burdens (for example, by assessing evidence on the value of diet and physical activity that might then be used in crafting model state legislation), a program designed to institute behavioral change among vulnerable populations at risk for overweight and obesity, an observational study design to explore how social determinants may affect health outcomes, and a practice-oriented assessment of policy issues facing local practitioners, among many others. The diversity in the case studies' topical content and structure is meant to avoid redundancy and foster the development of critical thinking skills. In practice, public health professionals often find that although many issues are implicated in a given problem, some disciplines will be emphasized more than others. Each chapter in this part begins with a listing of the disciplines emphasized in the case study. For example, some case studies focus on ethics and epidemiology while others focus on law and politics. Some case studies involve most or all of the disciplines in equal regard. In addition, several of these case studies offer focus exercises with examples that illustrate how to create particular documents or with sample scenarios for practice in applying specific concepts.
Part 3 (chapters 19 and 20) offers primers on two advocacy techniques: writing research policy briefs and crafting effective letters to the editor. Each discussion is followed by model examples.
This mix of educational, research, and advocacy approaches is intended to introduce students to the vast and, at times, exciting (or even frustrating) world of public health policy. And perhaps somewhere during that journey, like the porcupines who crowded together on one cold winter's day so as to profit from one another's warmth, all of us involved in public health policy shall discover that happy medium where we can most tolerably exist.
An instructor's supplement is available at www.josseybass.com/go/bhattacharya. Additional materials such as videos, podcasts, and readings can be found at www.josseybasspublichealth.com. Comments about this book are invited and can be sent to publichealth@wiley.com.
I must first thank the wonderful editorial team at Jossey-Bass/Wiley, including Andy Pasternack, Seth Schwartz, Kelsey McGee, and Justin Frahm, along with the editorial staff, for their patience, suggestions, and professionalism. The final product has undergone substantial improvements since its inception, with much credit to be given to the editorial team.
I must also thank those who participated in the substantive aspects of the work, including the expert interviewees—Patricia Freeman (Minnesota Department of Health), David Meltzer (University of Chicago), Patricia Bellock (Illinois General Assembly), Mark Kuczewski (Loyola University Chicago), and David Shoham (Loyola University Chicago)—and Lara Dugas and Justin Harbison, who coauthored the case studies on clean water and mosquito control and on the supplemental nutrition assistance program, respectively and Wiley Jenkins for his suggestions on the case-study on HIV criminalization. Their collective expertise has been instrumental in illustrating the breadth and depth of public health policymaking and analysis. I would also like to thank Lawrence Benjamin, MPH candidate at Loyola University Chicago, for his research brief that illustrates the utility of the primer on drafting a transparent and thorough research policy brief.
I would also like to thank the dean of the Loyola University Medical School, Linda Brubaker, for her support and encouragement of this project; senior faculty in the Department of Public Health Sciences at Loyola University Chicago—including our chairman, Richard S. Cooper, and Amy Luke and Holly Kramer—for their support; and Bamidele Tayo, Ramon Durazo, Jim Sinacore, and Ruth Kafensztok for their insights and encouragement.
I would like to thank proposal reviewers Christine Caruso, Carolyn Crump, Kay Perrin, and Ellena Young, who provided valuable feedback on the original book proposal. Carolyn Crump, Janice Frates, Tim Henderson, Laura Rusnak, and Kathleen J. Young provided thoughtful and constructive comments on the complete draft manuscript.
Finally, I extend my gratitude and affection to my wife, Christina, our children (and particularly our new addition), and my parents, Pranab and Indira Bhattacharya, for their support and patience throughout this process.
All errors in this work are mine alone, and if there is anything of worth, I attribute it to the collective wisdom and contributions of the individuals acknowledged here.
1. Arthur Schopenhauer, Parerga und Paralipomena, vol. 2, chap. 31: “Gleichnisse und Parabeln,” quoted in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud, ed. and trans. James Strachey with Anna Freud, vol. 18, Beyond the Pleasure Principle, Group Psychology and Other Works (London: Hogarth Press, 1921), 101.
2. Health Equity and Accountability Act of 2007: Hearings on H.R. 3014, Before the Health Subcommittee of the House Energy and Commerce Committee, 110th Cong. (June 24, 2008) (statement of James E. Clyburn, Majority Whip of the US House of Representatives).
3. Institute of Medicine, The Future of Public Health (Washington, DC: National Academy Press, 1988), 19.
Dhrubajyoti (Dru) Bhattacharya is director of the Public Health Policy and Management track of the MPH program at Loyola University Chicago; assistant professor of health policy in the Department of Public Health Sciences at the Stritch School of Medicine, Loyola University Chicago; and visiting professor of law at the Loyola University Chicago School of Law. He received his training from the Georgetown University Law Center and Johns Hopkins University School of Public Health. He is also among the inaugural cohort of the Global Clinical Scholars Research Training Program at Harvard University Medical School (2013 to 2014) and is completing advanced training in epidemiology at the London School of Hygiene and Tropical Medicine.
His research and teaching explores the intersection of public health, health policy, and epidemiology, with interests in domestic and global health and particular interests in health outcomes and quality, maternal and child health services, infectious disease control, and cancer prevention and treatment.