The Ebola outbreak in West Africa is an unambiguous reminder that social and economic conditions, like the lack of reliable public infrastructure in Liberia and Sierra Leone, are at the heart of many public health problems. In such an extreme case, public health and medical officials agree that once the epidemic gets under control, we must focus on improving these root conditions to prevent future crises. But even in the United States, where most places have reliable public infrastructure that protects people from such heart-wrenching scenarios, social and economic conditions lie at the heart of most serious public health issues and the inequities that result.
A new book, Expanding the Boundaries: Health Equity and Public Health Practice, released by the National Association of County and City Health Officials (a collaboratively written document with primary authorship by my friend Bob Prentice), focuses on the importance of social and economic conditions as keys to public health. Its central thesis is that “Health equity practice should consider the underlying social inequalities that are the root causes of health inequities, rather than only their consequences.”
Expanding the Boundaries begins by tracing the history of public health in the United States. Public health today takes a biomedical science approach – vaccines, laboratories, clinics, screening for disease. But many of public health’s most important advances were part of social reform movements responding to industrialization and urbanization. Reforms in sanitation, urban planning, food safety, child labor, and other areas resulted from public health advocates working with reformers in labor, women’s rights, housing, and other social movements.
The book argues that we must return to such collaborations to truly address the social determinants of health and health inequities:
The notion of an expanded health equity practice that can directly confront the sources of social inequalities is not a wistful claim to a romanticized history of public health. It is, rather, an argument that a public health that uses its resources, perspectives, commitment, and savvy to challenge the structures of power that create and maintain social inequalities and unhealthy living conditions is grounded in its own history.
It examines the root causes of health inequities – class, racism, gender inequity and heterosexism – and the structures that perpetuate these inequities. Disaggregating data, improving clinical management, and health education for specific demographic groups are all necessary, but not sufficient if we want to address inequity. “An expanded health equity practice,” NACCHO writes, “. . . asks how these [populations] came to be the way they are, and how public health might influence the forces that shape them rather than contend only with the consequences.”
Inspiring case studies – from Alameda County and San Francisco in California, Ingham County in Michigan, and the State of Minnesota – show how this can be done. Public health agencies in these places have been tackling such issues as goods movement, foreclosures, displacement, public transit, minimum wage, and planning and zoning.
Expanding the Boundaries identifies seven elements of health equity practice. For me, one resonates most and reflects where HIP is heading: “Some health departments have learned how to participate strategically in campaigns initiated and led by others, which might not be primarily about health but nonetheless advance health equity goals.”
This approach to public health is far from commonly accepted today and far from what is possible now in many places. But as the book concludes, “Developing health equity practice … is best seen as a movement-building strategy. It is a long-term process that requires a transformation of organizational culture and practice, and the larger public understanding of what most influences health.”