Each of the articles in this section describes efforts to improve what the title of this section calls the "capacity for policy development" in public health. One article describes disciplined political work with all segments of a community to create new policy that had broad-based support. Another describes a project in which public health professionals rejected full political engagement. The author of the third article revised it as a result of action to involve lawmakers in public health law reform that occurred after an earlier version of this commentary had been submitted to the editor of this journal and shared with a participant in the events described in the article.
Batson offers considerable evidence that access to health care can increase when "community-led planning" is done in fact rather than in name. The Chaves County project acquired strong, practical support from the county commissioners, members of a health planning council appointed by the commissioners, and 30 agencies and prominent individuals organized as the Community Care Network. In Batson's story, health professionals, including public health leaders, responded to priorities set by the council in negotiations with the Community Care Network.
The articles by Harrowe et al. and by Erickson, in contrast, describe projects in which public health officials decided what to include and what to avoid in developing policy. Harrowe and colleagues tell an absorbing story about the efforts of the Gila River Partnership to create governmental "public health structures" that can improve the health of a tribal community. A major impediment to this effort is that "Indian communities are often skeptical of their own governments." This "mistrust" is caused by tribal officials' "lack of resources to improve living standards on the reservation." But the leaders of the partnership appear to have avoided discussing ways to allay this mistrust with elected leaders of the tribe.
The partnership, perhaps justifiably, thus excluded from the scope of public health the problem of obtaining resources to improve living standards. The authors and leaders of the partnership may believe that there were no other options. Disagreement within the partnership, to which the authors allude, may have precluded discussing alternatives with elected officials. Whatever the justification, the professionals' priorities prevailed, not those of the public.
Professional priorities prevailed over both logic and, until recently, ordinary politics in the work of the Public Health Statute Modernization National Collaborative described by Erickson. The logical problem is the definition of public health law. Erickson reports that her colleagues in the collaborative "accepted the definition of public health law as proposed by Gostin" and then contradicted it. According to Gostin, public health law encompasses the "legal powers and duties of the state to assure the conditions for people to be healthy." These duties include "identify[ing], prevent[ing] and ameliorat[ing] risks to health in the population." Nevertheless, the collaborative decided that "it is not within our mission, nor would it be practical to attempt, to identify and develop models for the vast array of laws that affect the public's health."
The collaborative members' definition of practical may be related to the absence from the group of persons who craft and enact statutes. Because the collaborative did not include either legislators or attorneys general until recently, its members have been insufficiently sensitive to evidence that elected officials and their staff accord high priority to issues affecting public health that the collaborative chose not to consider. These issues include tradeoffs between health and the economy and the safety of food, air, water, soil, roads, vehicles, and workplaces.
By defining itself as a sales-force, moreover, the collaborative distanced itself from elected officials and the persons they employ to speak with leaders of interest groups, draft statutes, and analyze budget requests. Its self definition is in the first of its "desired outcomes," to "articulate a clear vision of Public Health that legislatures and other state agencies buy into." Unfortunately, elected officials and their staff are as wary as most Americans of salespersons.
After I sent this commentary to the editor, early in July 2001, I discussed it with Anthony Moulton, who directs the law program at the Centers for Disease Control and Prevention (CDC) and has been active in the collaborative (the participant I refer to in the first paragraph above). He told me that contrary to Erickson's account, inviting lawmakers-legislators and governors-to join the collaborative "has come up in every meeting I attended starting in April 2000."
Moulton and I recommended to the editor that he encourage Erickson to include this fact in the article. Erickson revised the article to say that:
At their most recent meeting [horizontal ellipsis] in August 2001, the Collaborative recognized the value of having a member who is a state legislator. [horizontal ellipsis] We had understood the value of this representation from the beginning and had planned to engage and invite input from state legislators through a variety of mechanisms such as focus groups and a state legislative conference on the model law.
It is, by definition, never too late to involve lawmakers in making laws. Moreover, Erickson also revised the article to call for a "partnership" of public health leaders and elected officials. Somewhat inconsistently, she did not delete the language that made lawmakers recipients of sales pitches.
I am more eager to understand than to complain about the inclination of public health officials to distance themselves from the ordinary processes and elected leaders of government. Before the bacteriological revolution in the late 19th century, making and implementing policy for public health officials was a collaborative activity. Participants in this collaboration included physicians (in private and public health practice), lawmakers, lawyers, civil engineers, urban planners, and business leaders.
The bacteriological revolution and the advances in the biomedical sciences that followed it changed the relationship among the occupations that governed public health. Many health professionals believed fervently that the steady progress of advancing science was the principal cause of improvements in preventing, detecting, and treating of most diseases. Many members of the public shared this overconfidence because the media and later movies and television romanticized the advances of science against disease. Public health leaders and the public no longer perceived law, engineering, business management, urban planning, and, above all, politics as equivalent in stature to medicine and other health occupations as public health professions.
For at least the past half century, however, the general public has been more enthusiastic about science and technology that could improve personal health services than about advances in the capacity of public health. Because funding follows enthusiasm, public health has been accorded lower priority by government than health care, despite its many contributions to longer life expectancy and better health status. Many public health officials understandably came to regard their profession as underappreciated as well as underfinanced.
Many public health professionals used ideology as an antidote for their dismay at the absence of esteem from the public, elected officials, and most physicians. According to this ideology, public health is a high-minded but insufficiently appreciated endeavor. The field has a moral as well as a practical claim to receive higher priority from voters and persons in elected office. Many public health leaders also said or implied that the field transcended mere politics. That is, they became advocates and behaved as all advocates do, even when serving as public officials.
All advocates want more resources. Importuning and often competing advocates besiege persons who hold elected office. The standard practice of legislators and their staff is to deflect or assuage them. Legislators, governors, and their staffs define advocacy by public employees as potential or actual disloyalty, especially when public employees collude with interest groups.
Thus, advocacy on behalf of public health has contributed to diminishing the status of the field and its practitioners. Advocacy in public health also has diminished the status of public health professionals by justifying their inattention to acquiring and practicing the skills of ordinary politics.
The three projects described in these articles are useful contributions to the literature of public health practice. Only one of the articles, however, describes what seems to be a turning point in a community. The other two describe pit stops. They are stories about people who refreshed their resources and then got back into traffic.