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Talking About Public Health: Developing America's "Second Language"
The mission of public health—improving the health of populations—is difficult to advance in public discourse because a language to express the values animating that mission has not been adequately developed. Following on the work of Robert Bellah, Dan Beauchamp, and others, we argue that the first “language” of American culture is individualism.
A second American language of community—rooted in egalitarianism, humanitarianism, and human interconnection—serves as the first language of public health. These values resonate with many Americans but are not easily articulated. Consequently, reductionist, individualistic understandings of public health problems prevail.
Advancing the public health approach to the nation’s health challenges requires invigorating America’s second language by recognizing the human interconnection underlying the core social justice values of public health.
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In their classic analysis of American culture, Habits of the Heart, Robert Bellah and his colleagues1 argued that the first “language” of American life is individualism. This is a language centered on the values of freedom, self-determination, selfdiscipline, personal responsibility, and limited government. The language of individualism is easy for most Americans to use, because it taps into values reinforced by dominant societal myths endlessly repeated in the popular culture. But although it may be this country’s first language, individualism is not a sufficient language for advancing public health.
Bellah and his colleagues also identified a second language in US culture—a language of interconnectedness. This is a language of egalitarian and humanitarian values, of interdependence and community. We have drawn on literature from the fields of sociology and political science as well as from public health to suggest how that second language could be more clearly articulated in order to talk more effectively to the general public, journalists, and policymakers about public health. By public health we refer in a broad sense to the question of how a society balances considerations of personal responsibility and social accountability in public policies that impact health. Public health focuses on the health of populations. But despite wide agreement among public health professionals on that general approach, what it means to focus on the health of populations is not necessarily well defined.
A substantial body of theoretical and empirical work shows that the state of the public’s health unavoidably reflects systemic forces as well as individual behaviors. Indeed, “a key class of determinants of health is the full set of macrosocioeconomic and cultural factors that operate at the societal level,”2 necessitating interventions that span the many levels of the society in which any given health problem exists.3,4 Ironically, many professionals in the field of public health believe in the importance of social determinants of health yet routinely rely on strategies that largely ignore social determinants in favor of individual, behavioral approaches to improving health. Although this disconnect between public health theory and practice has several sources, including the structural and philosophical limitations of conventional public health,5 a significant cause is the fact that a language to properly express the unique public health approach has not been adequately developed.
The lack of a well-developed language for talking about public health has serious consequences that extend beyond how public health professionals spend their working hours. Public policies that reflect the disciplinary theory of public health remain difficult to enact in the United States. Egalitarianism, humanitarianism, and social responsibility—values that lie at the core of a social justice orientation to public health6,7—often seem inadequate to respond effectively to the moral resonance of individualism. Yet in a culture preoccupied with personal responsibility and suspicious of governmental power, it is imperative for the public health profession to tap into these countervailing values in order to become more effective advocates for the public health approach to the nation’s many health challenges.