by S. Todd Stolp MD

©October 2013

 

There is something very comforting about the notion that the self resides between two shoulders, one bearing a tiny angelic image of ourselves encouraging selflessness and benevolence and the other bearing a little devilish self promoting indulgence and malevolence.  Unfortunately, in the public health world it becomes immediately clear that very few of the issues we face are good-bad, black-white, or true-false dichotomies.  Herein lays one of the main reasons why public health challenges are slow to respond to decision making and intervention.

 

Consider the issue of access to health care.  If the problem simply boiled down to the need for patients to find and pay for a health care provider willing to provide health care to them, the question of “access to healthcare” would be solved by the market like any other commodity.  However, healthcare is not a commodity.  In today’s world, “access to healthcare” is much more than meets the eye.  It includes the requirement that the patient retain active membership in a specific insurance company policy in which their selected healthcare provider is a willing participant.  The patient must understand the vocabulary of health insurance – such as premiums, deductibles, copayments and co-insurance – and they must have a functional understanding of the importance and benefits of preventive services – including immunization schedules, prenatal care, family planning and routine disease surveillance recommendations – so they can truly “access” those healthcare services.  In addition, unlike the decision to shop for a new television, the decision to seek care is often made by germs or the by the health of our internal organs and not by the whims of our brains.

 

A great deal of attention has recently been focused by public health experts on the “social determinants of health,” those factors and features of the world around us, including “community design,” that limit our life choices and which have enormous impacts upon our health.  The opposing argument to the importance of community design in our health is the case for “personal responsibility” – the idea that each individual must be accountable for the decisions they make on behalf of their own health, whether good or bad, given the choices before them.  Residing between the right and left shoulder in such debates can be deafening , but there are important tools available to us to help us sort through the noise, such as education and community planning.  With that in mind, our health is determined by both the neighborhoods in which we live – the availability of healthy food options in local grocery stores, opportunities for active transportation such as bike paths and pedestrian walkways, the quality of schools, the existence of multipurpose buildings and affordable housing, etc… – and our personal choices within the context of the cards we were dealt – our neighborhoods and our genetics.

 

Which brings us to one of the important light bulbs in the room.  Nothing can reveal the weaknesses of arguments from either shoulder as well as Facts.  For public health experts, this means facts about prospective controlled studies that document the effectiveness or lack of effectiveness of specific healthcare interventions, and facts about the outcomes of various policies on morbidity and mortality in various populations, and facts about social psychology.  For members of the public, this means facts about the influence of corporate marketing upon their consumer choices, and facts about the nutritional value or lack of nutritional value of food and beverage products, or facts about the new healthcare and health insurance choices made available through the Affordable Care Act.

 

No person is as vulnerable to the whims of the world around us as a person suffering from a vacuum of information, and nothing is as willing to fill that vacuum as the polarized arguments of the angels and devils that sit upon every shoulder.  Myths that spread with ease through our electronic conduits proclaim the risks of immunizations, the threats to our social relationships of dandruff and the paternalism of the “nanny state” and undermine the ability of the public to make rational decisions on behalf of their own health.  Public Health experts represent one of the only sectors of our society with the duty and the resources to counterbalance such forces.  We must continue to advocate maintaining and expanding those resources if we are to be effective in meeting our obligations to share facts with the public.

 

In addition, we must remain humble about our own susceptibility to the voices from our right and left shoulders and use facts to balance our own decision making, recognizing that small victories today lead one step closer to larger victories tomorrow.  Avoiding a sanctimonious tenor in our public messages can do wonders to build the public trust and enlist the public as partners in our efforts.