What is public health: DailyKos interview, part II

On Sunday DailyKos frontpager, DemFromCT (who is also a founder of the FluWiki and a pulmonary specialist) finished up his two part interview with us. It's cross-posted here below the fold. If anyone doubted we were academics, the display of watching us argue with ourselves would have but those doubts to rest. Scientists cherish the hope that we will make difficult things simple, but often we wind up making simple things difficult. We see complications in everything, even the simple question of what is public health infrastructure. Witness:

Q. Last week I asked you about public health infrastructure in relation to being prepared for a flu pandemic and instead of answering me directly, you made it into an abstract question. Surely it can’t be as difficult as all this.

LOL. You are probably right. Trying to define what infrastructure is in general is probably a fool’s errand. But remember how we reveres got into the flu business. I'm a cancer epidemiologist whose research is quite theoretical, so our many posts at Effect Measure on flu and pandemic preparedness might seem out of character. But, like you, we are also activists and four years ago, in the dark days of early Bush II, preparing for a potential flu pandemic seemed like a perfect lens through which to look at public health. It had all the elements: distorted priorities, incompetent government, political interference with science, destruction of the public health system by ideologues, etc., etc. But the science is also fascinating and so we have spent a lot of time on that, too. And one of the things the science teaches us is that much of what we thought we knew about flu is wrong. Which encourages taking a hard look at everything, so it's all of a piece.

Still, there's a job to be done and it can't wait for all the arguments to be settled. So we wind up doing practical things and theoretical thinking all at once, in parallel and iteratively. Sort of like when Boston built a major highway (the Big Dig) underneath the existing Central Artery while the Central Artery continued to carry the full load of rush hour traffic. It's messy and probably inefficient, but we don't know any other way to move ahead. I mean really move ahead, not just turn the same crank on a machine that never worked that well in the past. The fact that a bunch of crooks and incompetents wanted to abandon that machine altogether doesn't endow it with any greater powers, retroactively.

(Laughs) There! I did it again. I didn't answer your question but went off on a tangent about politics. But remember, public health has the word "public" in it. It is inherently political and if we don't recognize that we will wind up tinkering with something that won't ever be able to do the job we need it to. It's sort of like a hill climbing algorithm in computer programming. If the program works by taking wherever we are on the hill and always moving to higher ground--a classical incremental approach--we will get eventually to the top of the hill, but we have foregone the possibility of going back down and choosing another nearby hill whose summit is even higher. Maybe the hill we are on is the best around, but I doubt it, so I am not satisfied to just discuss this in terms of public health as we have it now.

Q. Too abstract and handwaving for me. Can you at least start to pin it down a bit?

Well, maybe we can make it a little less abstract by asking what kinds of projects warrant significant social investment and why. Here we'd be specifically interested in public health or social service projects, because roads and the electrical grid are necessary for both public health and social services to function but including them as public health infrastructure seems a bit gratuitous (although not illogical). Unfortunately the first thing we see when we ask it this way is that it opens up a whole new set of difficult questions, like what do we mean by public health and what would warrant investment. I think these questions are answerable and I will take a preliminary stab at answering them, but I still feel compelled--and compulsion is probably the clinically apt term in my case--to give it a political preamble (we Reveres are indeed incorrigible).

We in progressive public health - the circumlocution du jour for public health’s left wing -- haven’t done our job in thinking all this through, instead gone on for decades mouthing slogans like “Prevention Pays” and “Health is a human right.” What if prevention didn’t pay? Does that mean we wouldn't do it? And where does this supposed "right" come from ? I don’t feel like trekking the vale of tears that is an argument from Natural Law nor the legalistic one of Constitutional Rights. I want to have a well-founded argument about what health-related things should be guaranteed to every citizen and which ones not and why. And I can’t do that at the moment because we on the Left haven’t done the difficult theoretical labor of thinking it through. Just trying to answer the question about what should be considered infrastructure has become a major project because I don’t think we have a clear way to think about public health.

Instead we reflexively use a tired and impoverished conceptual frame of reference. Our public health world consists of people with various features we call “risk factors.” We look at different health states and ask what risk factors they are associated with. Then we think about altering the risk factor profile. This is a perfectly adequate way to frame certain practical questions but in my view it isn’t very helpful for the bigger questions, even when accurate (and it isn't always accurate). It tends to slide over bigger questions like why people have the risk profiles they do (other than to blame their genes) or what are the appropriate ways to intervene in changing which risk factors. I’ll grant this is a broad brush indictment and I have many colleagues with much more nuanced and enlightened views, but it isn't too far off the mark for public health as a whole. It is a field whose habitual mindset is constricted and circumscribed.

Q. Well if you aren’t going to use the dominant paradigm for public health, what are you suggesting public health is?

I don’t have a fully developed answer, so instead let me give an illustration of the kind of alternative answer that hard thinking might provide. It might not be the right one but it's an illustration. Then maybe we can get back to the infrastructure questions.

A colleague once referred to a nice definition of public policy as those things we as a community have chosen to do for each other (I wish I knew a source to credit). We could also say about public health that it consists of those things that we as a community have chosen to do for each other with regard to our physical and mental well-being. This is quite different than the risk factor approach to public health. It shifts the emphasis to politics by putting what we as a community choose to do, not for ourselves, but for each other. It also allows a more nuanced answer to what physical and mental well-being is because it leaves it more open. Political leadership is obviously critical because what a community in a democracy decides it wants to do is always heavily influenced (although not determined) by where its leaders are taking it.

So what should we choose to do for each other? I have two kinds of answers. One is that we should do things that will produce the kind of world I want to live in. I don’t want to live in a world full of sick and miserable people. I want to live in a world where people, by and large, are satisfied and happy. But maybe that’s just me and my conception of a good world. We do this kind of thing a lot. We take our own political positions and relabel them as things public health should do. For our own sakes, if for no other reason, we should have a better way to validate what we think. Maybe some of it needs to be rethought. Shouldn’t there be a more intersubjective way to go about this? I’m not a philosopher so I have probably brutally simplified this, but I find the basic Rawlsian notion of a Veil of Ignorance is helpful. What policies would a rational individual wish for were placed in a position of total ignorance of all his or her risk factors, e.g., income, social advantages, biology. If any person had some appreciable chance of starting afresh without access to health (for any of a number of reasons) or specially vulnerable (for any of a number of reasons), what kind of world would be the best one to live in? What policies would maximize an arbitrary person's opportunities to live a decent life should it be revealed they had been dealt a bad hand when the veil was withdrawn. Does a biodefense laboratory -- which is quite plausibly a part of public health infrastructure -- produce a better world in this sense? Or should we first choose to deploy services and resources to make the most disadvantaged less disadvantaged? This gets closer to what I mean by strengthening our public health and social service infrastructure, building the brick house to withstand whatever may come.

This isn’t a test that’s easy to apply and there will likely be many instances where multiple paths forward are indicated. It is a way of thinking about public health and its choices. Sketching those paths and deciding which ones not to go down is what I mean by the hard labor of thinking this through. It’s not an answer to your very sensible question but it is a way to start answering it.

Q. OK, so let's return to the infrastructure question. How does this apply?

I've been the habit of giving easy answers to the infrastructure question, and there are some. But as you can see by the way I've answered above, I'm not particularly happy with the depth of thought that went into what I've said. Still, I think it's pretty safe to say there are some things that qualify for "shovel ready" investment in public health infrastructure.

I'd start first by rebuilding our tattered and demoralized local public health system, meaning state and local health departments. They've been decimated by years of budget cutting. Of particular importance are the things already recognized as infrastructure within those departments, the IT and communications sectors, surveillance, vital records, outbreak investigation capabilities and some of the information gathering needed to administer a 21st century health system, like inventories of available and staffed beds and particular kinds of facilities. In many states health departments are required to collect this information but have stopped doing so. Of course the diagnostic state laboratories are included in this.

One thing to notice about this list is that it involves gathering information. Information is not only necessary to support almost all public health and social service functions, but it's what economists call a non-rivalrous resource: it isn't used up when it's accessed. It's still there for others to use. This is also true about knowledge, so investment in basic and applied public health and medical science is investment in a critically important element of infrastructure: information and knowledge. That's NIH budget. But information and knowledge are not generic kinds of social capital. It has to be the appropriate kind of information and knowledge and it has to be accessible to everyone. And while the product is non-rivalrous, producing it still takes resources. Investment in one kind of knowledge can preclude producing another kind of knowledge. I have argued that generating some kinds of knowledge and some kinds of infrastructure enterprises are harmful to public health. Regarding accessibility, public health is a global enterprise. What happens in a rain forest or on a dairy farm in rural China can affect other people anywhere in the world. Information and knowledge that is not accessible to all is not part of the public health infrastructure. So there are some knotty issues about intellectual property and common benefits that have to be sorted out. So while some kinds of things seem easy on the surface, they often turn out to be difficult and require the more thorough kinds of analysis I already mentioned.

I have been quick to say that public health preparedness, whether for a pandemic or something else, requires a strong and robust public health system that includes all its parts: not just surveillance and disease outbreaks but maternal and child health, substance abuse programs, inspectional services, etc. My rationale here is a little different. They represent another critical kind of capital, human capital. The more people trained and experienced in public health we have the better able we will be to withstand the kind of shock a pandemic would cause. When catastrophes happen people rise to the challenge and can do amazing things. But it's much better if they also have trained reactions, knowledge and experience. We saw an object lesson with the ditching of the US Airways plane in the Hudson River. Yes, luck was involved, but this was an experienced, prepared pilot and crew, and that likely made the difference. There is no shortage of young people in this country who want to put their shoulders to the public health wheel. We can invest in training them and providing experience by requiring two years of national service in exchange for free tuition to any School of Public Health. Who would you rather was piloting your plane? Someone who wrote the software for a Boeing 747 flight simulator or someone who has spent years flying commuter airline planes? By ramping up training and assuring staffing in state and local public health we can strengthen a critical portion of the public health infrastructure.

I am only sketching some things that are begging to be made into detailed proposals. But they are the kinds of infrastructure that will pay off handsomely, the low hanging fruit of investment. Meanwhile, there is also some hard thinking that needs to be done about the whole enterprise we are engaged in.

Q. OK. I can see that if I really want to pin you down, I'm going to have to be very specific. Recently the reveres/Reveres have been posting very specifically (here, here, here, here, here and lots more) on the salmonella in peanut butter episode (someday I want you to explain why sometimes it is reveres with a lower case r and sometimes with an upper case R, but I'll leave that for another time or maybe consider it just one of Life's Enduring Mysteries). What's your take on food safety? Specifically, is our food chain safe?

Specifically? Without the political musings? That reminds me of a joke whose punchline is, "I always think of screwing," but I'll do my best to think of something else.

First, like you, I frequently use the common phrase "the food chain," but there is nothing chain-like about it. A chain is linear. One link follows another. But our food production and distribution system is more like the blogosphere itself, a network of interconnected nodes, some with few readers (personal blogs read by no one or just a few friends, like a kitchen is), some with a modest number of readers (like Effect Measure, with its small but specialized community, more like a restaurant), and then megablogs like DailyKos that are highly connected to hundreds of thousands of readers and other connected nodes (a big manufacturer or meatpacker, distributor or ingredient maker). We may think of the food system as "centralized" because there are megadistributors but in fact a problem can be introduced at any point, and in the peanut butter episode it wasn't a distributor but the maker of a common ingredient in a lot of other products, peanut paste. The malefactor, the Peanut Corporation of America, is not even one of the industry giants, like ConAgra (who also had a problem in 2007 with their Peter Pan brand peanut butter).

If you think of the food system as the blogosphere you can see immediately what can happen. It is a system that is a set up for delivering nutritious, health giving products to a lot of people (DailyKos) or adulterated products to unsuspecting or ignorant consumers (Michelle Malkin). A contaminated highly connected node in the food network like the Peanut Corporation of America is like Drudge, providing adulterated ingredients to a gluttonous MSM, who serves it up to everyone. Here the analogy breaks down, because I don't advocate regulating the contents of the blogosphere (as much as sometimes I'd like to). The food network, however, does need to be better regulated. Consumers cannot isolate themselves from the bigger food network, which also includes water, soil, air and seed stock, so even eating locally grown food, something not feasible for most people, doesn't eliminate the problem.

For this and other reasons fixing the food system is a big task, and various proposals are in the works in Congress. One of your representatives, Rosa DeLauro (D-CT, Third District), has introduced a bill to consolidate food safety oversight into a single agency, instead of spreading responsibility for monitoring, inspecting and labeling over the current 15 agencies. At the moment consumers don't know the distribution of recalled products, and it appears that even the FDA didn't know initially where PCA's peanut paste went because there is no requirement to notify the agency of where ingredients are distributed. The industry has maintained that access to this kind of information must remain private because it could be used by competitors. Yes, theoretically true, so that's a trade-off. But the same people who wring their hands over confidential business information seem to have no trouble with my privacy. We know they have violated all of our privacy using doubtful (I'm being generous) arguments about national security. That's a trade-off they are only to eager to make. But information that protects children from contaminated peanut butter cracker snacks? Note that half of the 500 salmonella cases from this outbreak are children.

Whatever agency we wind up with (either the discoordinated mosaic we now have or a consolidated agency), it will have to be adequately staffed and with sufficient infrastructure (see, we did get back to it!). Staffing is human infrastructure. Right now there is insufficient inspection because there aren't enough inspectors. The laws are legal infrastructure. There needs to be legal authority, authority that is used and sanctions that are enforced, to make sure the nodes in the food network operate according to best practices. There needs to be laboratories capable of doing the high through put urgent analysis of food samples from the field in the event of an outbreak. That's physical infrastructure. There needs to be research and information on food safety, developed by supported and carefully conducted research on things that are still uncertain. That's intellectual and scientific knowledge infrastructure.

This is just for starters, but it's all infrastructure investment because the system is in urgent need of repair. Part of that infrastructure just fell down and injured over 500 people and killed 8 of them. The fact that it was salmonella and not a bridge collapse is not very relevant to the victims.


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a sincere thanks Revere,

it was great to follow along the reasoning in Q3 from the perspective of a young person who is trying to understand broad frameworks from which someone in public health can operate within.

Reading this reminded me of a story by Stanislaw Lem in the Cyberiad, about The Kingâs Perfect Advisor built by the robot constructor Trurl for King Genius.

The first thing the king asked for was advice on how to not pay the price agreed to. The Kingâs Perfect Advisor was of course able to give advice that was completely effective for this. All Trurlâs attempts at receiving payment are thwarted by The Kingâs Perfect Advisor. Eventually Trurl resorts to playing on the Kingâs stupidity and suspicion to undo The Kingâs Perfect Advisorâs perfect loyalty and perfect advice.

That is the most important aspect to public health, the collective wisdom to follow good advice.

Seems to me a vital ingredient is to educate the public to be more aware.

Take something as simple as hand washing! When was the last time you saw, in any public bathroom, a sign saying something to the effect of, "prevent the spread of disease: wash your hands"...? For that matter, how'bout at restaurants: a simple line of text on the menu saying, "after you order, and before your food arrives, please wash your hands"...? How'bout at the grocery store, in the produce aisle and at the meat and fish counter: "always wash your hands before preparing food," and "always wash your hands after handling raw meat"...?

Or, how many employers insist that sick employees come to work, either under threat of dismissal or with the subtle coercion of loss of pay during illness?

When people understand how disease is spread, they are more likely to take the simple steps to "not share it."

This ties in with effective use of media, and effective science education in the public schools, and economic & business policy... etc.