Policy, systems, and environmental change: the current, faddish, cow-patty flavor of public health

One thing I have never shaken since my days as a rookie reporter is my penchant for calling out the obvious. This is one of the sacred duties of the press: to speak truth to power. This also means calling a spade a spade, and bullshit for what it is, and what it smells like.

Anyone who has ever worked in the business of reporting news and telling facts knows this is one of the press’s sacred trusts—and myths—and the clearer we are in doing that, the better our society is from having that unbiased information.

I captured these various images on Google when I typed in a few keywords, and clearly this concept has a lot of widespread acceptance by people who know a cow patty when they smell one.
I captured these various images on Google when I typed in a few keywords, and clearly this concept has a lot of widespread acceptance by people who know a cow patty when they smell one.

Today, I stumbled on Marcy Wheeler’s blog, the Empty Wheel, which tackles many hot-button policy issues. Last year she blogged about climate change in a piece called “The Cost of Bullshit: Climate Change, National Security, and Inaction.”  She pointed out that the cost for maintaining the status quo was too high, even when major government agencies from the Department of Defense and the Department of State concluded that the issue was a critical concern to U.S. national interests. Yet, no actions were being taken by the government, and all of the reports on the emerging crisis were “mere bullshit—more wasted government employees’ time and taxpayer money.”

Sure easy for a blogger not on the payroll to diss hard-working public workers and policy-makers, right? Or, is Ms. Wheeler simply calling out the obvious, like reporters have always done, or thought they were doing.

Will a public health fad meaningfully address the main killers of Americans?

The cost of bullshit has been on my mind late, particularly regarding public health jargon that inflates busy-looking arm-waving, but does not change reality.

For me, one of the most frustrating aspects of working in the public health is the field’s faddish way it labels its collective actions to address chronic disease issues, such as obesity, using fancy sounding concepts like “policy, systems, and environmental change.” Mon dieu, what big words, what big ideas.

This is an expression coming from the top, from the venerable U.S. Centers and Disease Control (CDC), to explain national efforts to tackle the monster that is chronic disease—the leading causes of death in our ever-fattening and ever growing income-unequal country.

These diseases kill seven in 10 Americans, and of the CDC’s meager budget of under $7 billion for our national public health effort is a mere drop in the bucket compared to other priorities of the $1.2 trillion national budget that is so-called “non-discretionary spending.”

The Congressional Budget Office released this info graphic on government spending and revenues for 2013. Go here for original: http://www.cbo.gov/publication/45278.
The Congressional Budget Office released this infographic on government spending and revenues for 2013. Go here for original: http://www.cbo.gov/publication/45278.

The CDC still estimates 18% of U.S. GDP spending is on healthcare, and a third of it at the place where the most outrageously overpriced and at the same time least effective primary care interventions can take place—hospitals.

So what do public health officials do, when faced with a handful of breadcrumbs thrown to them from Congress? They invent concepts that make it appear that public health is doing something, when there is little or no clear evidence population benefits are accruing based on investments at this level in the large ocean. Yes, I am talking about the catchy and jargon-laden ideas like “policy, systems, and environmental change.”

This is a hodge-podge of activities that encompass everything from starting farmers markets to promoting smoke-free buildings. Here are a couple of definitions I randomly found from some online sources:

  • State of Mississippi: “Our environment and the policies and systems in it shape the pattern of our everyday lives and have a profound influence on our health. The design and walkability of communities, the availability of low-cost fruits and vegetables, and the smoking policies in our workplaces have a direct impact on our physical activity, diet and health.”
  • State of Maryland: “Policy, systems, and environmental change (PSE change) refers to public health interventions that modify environments to provide healthy options and make healthy choices easy for everyone.”
  • Fairfax County Virginia: “Policy, systems and environmental change is a way of modifying the environment to make healthy choices practical and available to all community members. By changing laws and shaping physical landscapes, a big impact can be made with little time and resources. By changing policies, systems and/or environments, communities can help tackle health issues like obesity, diabetes, cancer and other chronic diseases.”

Budgets for this kind of intervention exist in most public health jurisdictions, and public health leaders are doing to the talk, because they have so few funds to do the walk. But public health experts end up playing in a small sandbox when these investments are measured against other spending, and then we spend a lot of time trying to convince ourselves through published papers, webinars, conferences, and the like that this is working. The illusion is powerful, like the illusory power of the Iron Throne in the Game of Thrones, except the shadow from a fad still does not make meaningful change when the numbers are crunched and the costs are calculated regarding chronic disease.

From the Game of Thrones, a lecture on power and illusion, for Westeros and beyond.
From the Game of Thrones, a lecture on power and illusion, for Westeros and beyond.

Public health departments who get funding through competitive grants from the CDC spearhead these efforts and then spend extensive amounts of time documenting their work trying to prove the bread crumbs made a difference to the overall health crisis facing Americans.

About $200 million was doled out from 2011 and 2012 through an effort called Communities Putting Prevention to Work (the amount initially announced in 2010 was about $380 million). In one case, Public Health-Seattle & King County published findings that show its CPPW-grant-funded efforts in schools cut youth obesity in specific schools by 17 points. Great job, except the funding was not permanent and it was not renewed when the grant ran out. The program is now in the past tense.

In 2014, public health professionals learned another funding source, the Community Transformation Grants, which also promote the policy, systems, and environmental work, is being cut too. Some can argue the money is being allocated to other programs that tackle chronic disease, focusing on heart disease and diabetes.

More musical chairs without really changing the big picture again?

I do not mean to belittle the work of public health people doing this work. They are my colleagues. I respect them. And the work being done, like promoting activities to reduce tobacco use and get more people eating healthy food, should be continued.

But as a field, I am convinced this type of work is self-delusional because it hides the nasty realities of how much larger issues shape the public’s health, such as how transportation budgets are allocated, how cheap petro-based energy is spurring obesity in measurable ways, how legislation is crafted by special interests at the state and federal level, and how the principle of health care is considered a privilege not a right in the United States. (In Denmark, by contrast, the public funds about 85% of all health care through taxes, and the system is rooted in both law and a social contract that is premised on system where all citizens are provided free and equal access to quality health care.)

Emilia Clark, mother of dragons in the smash HBO TV series Game of Thrones, is a good visual metaphor of what public health is not in the bruising world of budget appropriations at the state and federal levels of government.
Emilia Clark, mother of dragons in the smash HBO TV series Game of Thrones, is a good visual metaphor of what public health is not in the bruising world of budget appropriations at the state and federal levels of government.

The nasty realities we do not want to think about, using a contemporary TV metaphor, would be what happens when the violent kings of Westeros cut deals and cut heads, to maintain order in that mythical, lovable place with White Walkers, a giant ice wall, and fire-breathing critters. Mother of Dragons, public health is not, that is for sure!

I imagine a new fad will emerge in public health in the next three years, like it does in management. We might change the concept, but we likely may even have a smaller piece of the government pies.

No, public health jurisdictions cannot stop working until we see changes on these fronts. But the more we in public health delude ourselves that we are making a difference with scraps from the table, the more easily we are duped into accepting that the larger model is as it should be, and how it shall always be.

We will continue kvetching about farmers markets and soda machines, but not moving in a rigorous way upstream, where budget deals are made with transportation dollars, for starters. And I think we have to start being honest with ourselves about what we are accomplishing in the sandbox and whether this is the best use of our meager and diminishing resources.

The politicization of public health (and everything else too)

maherobama
Click on the photo to open a link to the video clip of Maher’s commentary.

Some might say TV host Bill Maher is so political that he cannot be trusted. I disagree.

On March 8, on his TV show, Maher delivered a very provocative commentary that everyone in the field of health promotion, public health, and public policy should watch. Maher rightly asked, “Since when in America did everything have to be so political?” It was a smart piece of punditry, because he correctly showed how efforts to promote public health, nutrition, and healthy eating had become as politicized as the debate over regulating the proliferation of firearms.

Showing pictures of First Lady Michelle Obama, a champion of a national nutrition and exercise campaign called Let’s Move, Maher opined, “If seeing this nice lady on TV saying she likes the movies, or nutrition, or exercise fills you with rage, get help.”

Maher further correctly noted, “Big portions, conservative; knowing where your food came from, liberal.” In short, Maher said what few in the public health profession are saying or have the courage to say—that a deep schism exists in the public space that taints and will continue to taint all efforts to tackle some of this country’s biggest health problems.

These include the obesity epidemic and the threat posed to our healthcare system and our national health by chronic disease.

Ever a political lightning rod who is ready to fan conservative flames, former half-term Alaska Gov. Sarah Palin used her speaking appearance  at the 40th annual Conservative Political Action Committee (CPAC) conference on March 16, to lambaste New York City Mayor Michael Bloomberg’s efforts to tackle obesity by limiting the size of sugary-sweetened beverages. Bloomberg’s New York City law to limit the serving size of such drinks to just 16 ounces was  overturned by a New York State Judge on March 11.

This perfectly framedAP file photo from March 16 shows Palin's eager embrace of red-meat politics that seeks to prevent small measures to address the proliferation of obesity in the United States.
This perfectly framed AP file photo from March 16 shows half-term former Alaska Gov. Sarah Palin’s eager embrace of red-meat politics that seeks to prevent small measures to address the proliferation of obesity in the United States.

Completely ignoring the obesity crisis that is afflicting her own former state and the country, where two-thirds of all residents are obese or overweight, Palin slurped soda from a 7-11 Big Gulp. The theatrics, all perfectly inline with Palin’s anti-government theology, again proved Maher’s point about the politicization of even micro efforts by some local elected officials to address the public health threats facing the country. (Side note, Palin briefly was governor when I lived in Alaska, and I saw her at health promotion events like community runs–an action that she likely would brand as “liberal” today.)

Whenever I would engage Puget Sound area public health officials during my two years of study at the University of Washington School of Public Health (2010-’12), I always asked, how can you prevent the public perception that efforts to promote healthy activity and nutrition are not perceived by conservative voters and Republican elected officials as part of a liberal, activist agenda. I never got a good answer, mainly because I do not believe those officials had an answer. I did not draw any great wisdom from my faculty or UW SPH peers either.

Some wonkish types have tried to investigate this issue in “philosophical terms,” along traditional axes of egalitarianism/choice minded conservatism against regulation-minded “big government” liberalism. One 2005 article on responsibility in health care choices argued, “Holding individuals accountable for their choices in the context of health care is, however, controversial.” There may be some truth to this, but I discount the “core political values” explanation as a way of understanding the politicization of public health initiatives.

Perhaps the biggest fight  in the U.S. political system today is over tax policy and the future of major social/medical programs—Social Security, Medicare, Medicaid—that provide the true underpinning to the public wellness of our country. This is, at its core, is vicious political battle that will shape the public health of the country unlike any action taken by any regulatory or health agency of the U.S. government.

Regulation to promote health has been at the heart of the public health enterprise ever since the field emerged as a profession in the United States in the late 1800s. According to the Centers for Disease Control and Prevention, many of the most successful public health achievements of the 20th century  (food safety, motor vehicle safety, identifying tobacco as a health hazard, etc.) were “upstream” interventions that, by definition, were regulatory in nature and thus purely political.

However, public health, by being a public enterprise, is by definition a creature of the political process, and thus influenced through the power of the purse to curtail its authority and stymie its reach. Public health departments today, for instance, are managed by publicly accountable officials. A local public health department board of health, like King County’s, includes a broad range of elected officials and a few medical professionals.

The nation’s leading de facto public health official, the U.S. Surgeon General (Dr. Regina Benjamin), today remains a mostly toothless position that has little if no sway over the public policy debate concerning the nation’s public health, according to New York Times health blogger Mark Bittman. He writes, “… there is no official and identifiable spokesperson for the nation’s public health, and the obfuscation and confusion sown by Big Food, along with its outright lies and lobbying might, has created a situation in which no one in power will speak the truth: that our diet is making us sick, causing millions of premature deaths each year and driving health care costs through the roof.”

I personally believe that the position of Surgeon General remains that of a paper tiger because those who have power, members of Congress and the Executive Branch, do no wish to allow an advocate for public health to embarrass them with pesky things like facts and science that call for action.

Dr. C. Everett Koop, former U.S. Surgeon General and effective communicator and advocate for public health.
Dr. C. Everett Koop, former U.S. Surgeon General and effective communicator and advocate for public health.

The most effective Surgeon General in living memory who recently passed away in February, the late Dr. C. Everett Koop, proved unpredictable. Though a staunch conservative appointed by President Ronald Reagan, Dr. Koop staked out very controversial political positions on moral and medical grounds, in defiance of his boss, Reagan.

His notable actions still stand out today for their audacity to challenge powerful interests and their embrace of morality as a tactical advocacy tool:

  • Koop’s office produced the plainly worded, 36-page “Surgeon General’s Report on Acquired Immune Deficiency Syndrome,” which clinically detailed HIV transmission, making clear it was not spread by casual contact and affirming that, “We are fighting a disease, not people.” Koop promoted sex education and condom use, enraging conservative critics.
  • Koop also took on the all-powerful tobacco industry and lawmakers who received its many contributions with his pronouncements that smoking killed and should be banned. He famously called purveyors of cigarettes the “merchants of death.” (When is the last time anyone has heard a medical leader embrace such powerful language for a public health cause?)

Though Koop reportedly claimed morality never “clouded his judgment,” he remained an effective advocate on the bully pulpit by literally shaming those in power. “My whole career had been dedicated to prolonging lives,” he said, “especially the lives of people who were weak and powerless, the disenfranchised who needed an advocate: newborns who needed surgery, handicapped children, unborn children . . .people with AIDS.”

I keep waiting for someone, anyone besides billionaire Mayor Bloomberg, to enter the political discourse on behalf of public health and use straight language that cuts through the hype. The problem is, they cannot teach you leadership when you enter the fields of public health or politics. It is something you either are capable of, or simply lack. Right now, it is lacking.