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Talking About Public Health: Developing America's "Second Language"

by Lawrence Wallack, Regina Lawrence

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.

Values and Public Health in the United States

Although it is useful to analyze cultures in terms of their dominant beliefs, cultures of developed societies typically exhibit multiple value systems, with various subgroups weighting those values differently.8 Despite the well-documented prominence of individualism in US culture,9–11 equality, compassion, community, and social responsibility have, throughout US history, motivated people, particularly marginalized groups, to act collectively to address social problems.12, 13 Although support for egalitarian values is more limited in the United States than in many other Western democracies, and the term welfare is highly unpopular,14 many Americans nevertheless believe that government and society have a responsibility to ensure that the opportunities to build a successful life be enjoyed roughly equally by all—beliefs that, research shows, are rooted in humanitarian values.15–17

Empirical research also suggests, however, that most Americans do not articulate these values nearly as easily as they use the language of individualism. For example, when researchers asked members of the public to explain their support for or opposition to social welfare policies, they found that those who opposed such policies did so in terms of abstract principles like personal responsibility and limited government. But the abstract principles of equality, fairness, and compassion that underlie social welfare policies were not readily articulated even by supporters of those policies.18 In other words, these people knew that they supported these policies, but they couldn’t easily explain why.

And therein lies the rub: these values of equality, fairness, and compassion are closely associated with public health. One of most visible definitions of public health is “the process of assuring the conditions in which people can be healthy.”19 In the context of public health, each element of that definition—process, assuring, conditions—evokes values beyond individualism. Yet the predominance of the first language of individualism makes the mission of public health often seem somewhat alien to the general public, as well as policymakers, journalists, and other elites.

For example, public health focuses on “conditions” that make populations more or less healthy, which shifts both the causal explanation of public health problems and their potential solutions away from a sole focus on individual choice. These are relatively complicated explanations compared with the simple ones generated by the more reductionist language of individualism. Take the example of obesity: it is much simpler to believe that people are obese because they eat too much and don’t exercise enough. News coverage has framed the issue predominantly in terms of personal responsibility, the frame also favored by those who oppose policy changes such as eliminating junk food from schools and requiring better food labeling. Although the balance of public discourse now seems to be shifting, until recently most news coverage did not convey the idea that people are also obese because our society is organized in a way that encourages overconsumption of fatladen, high-calorie food (through advertising, marketing, and an economic system requiring 2 wage earners) and limits outlets for physical activity (for example, by elimination of physical education in schools and heavy reliance on automobiles).20 In the first language, the point that people need more self-discipline simply needs to be asserted and its assumptions (e.g., personal responsibility) are intuitively grasped and expected conclusions reached. In the second language, the point that society needs to be organized in a healthier way must be explained, because the assumptions (e.g., social accountability, shared responsibility) are not easily grasped and the conclusion needs to be argued.

As cognitive linguist George Lakoff has revealed, the metaphors underlying the language of individualism form a coherent and compelling package rooted in widely accepted moral values.21 The political virtues of limited government and personal responsibility correspond, at a subconscious level, with many Americans’ mental model of personal morality in which self-reliance is a moral obligation. Government policies that interfere with the mechanisms of personal responsibility and self-discipline are therefore seen, in a sense, as immoral. Thus, a predominant belief is that “people should accept the consequences of their own irresponsibility or lack of self-discipline, since they will never become responsible and self-disciplined if they don’t have to face those consequences.”21 When seen through this lens, many social welfare and public health policies look like wrong headed efforts to “protect people from themselves,” thus (immorally) undermining self-discipline.

Consequently, the language of public health seems foreign (“Sounds like central planning— didn’t they fail at that in the old Soviet Union?”), and its paternalistic objectives and methods for protecting the health of populations (government as national nanny) can be difficult to support. Even the public health data amassed over the years that demonstrate empirically the relation between social inequality and health inequality22–25 can be hard for the public to understand, in part because the predominant moral framework makes it easier for people to imagine what one person might or might not do to be healthy compared with what society might collectively do to ensure health for the population. Thus, individualism, as the “dominant orientation in the United States . . . profoundly restricts the content of public health programs.”5(p25)

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