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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.

Developing the Language of Interconnection

As Dan Beauchamp,6 Ann Robertson,7 and others have noted, the moral framework underlying the public health approach differs from the predominant moral framework of individualism. Robertson argued that health promotion “represents a moral/ethical enterprise” and that the language of public health is essentially “a moral discourse that links health promotion to the pursuit of the common good” (emphasis added).7 Focusing on the health of populations inevitably raises questions about the health effects of how society is organized—questions difficult to raise in a public discourse suffused with individualism.

Perhaps intuitively recognizing this difficulty, many public health advocates tend to fall back on a language of service provision and behavior change— clear, concrete, easily understandable approaches. But that strategy reinforces the first language of individualism by emphasizing a risk factor approach that leads to a discourse about behavioral strategies and treatments for existing conditions.5 Discussion of social, political, and economic context is often only cursory. When these contextual issues—the more complicated story of public health—are not discussed, their importance is implicitly diminished and efforts to improve the health of populations are weakened.

To advance public health with the necessary comprehension and urgency requires articulating an overarching value that we call interconnection. Interconnection is not a new idea. It invokes long-held ideals associated with the words public, social, and community. Indeed, as Dan Beauchamp argued nearly 20 years ago, the practice of public health is premised on a “group principle” that “has tended to be subordinated to the language of individual rights.” But “public health as a second language,” he wrote, “reminds us that we are not only individuals, we are also a community and a body politic, and that we have shared commitments to one another and promises to keep.”26(p34) Echoing Beauchamp, Robertson7 called for the development of a “moral economy of interdependence” in which beliefs about justice and need are informed by a sense of mutual obligation that “acknowledges our fundamental interdependence.”7(p124)

Various contemporary thinkers have also begun to develop this language of interconnection. Lakoff,21 for example, envisioned a language of “cultivated interdependence” in which those who have been nurtured accept a corresponding responsibility to nurture others. Political theorist Mary Ann Glendon27 argued for challenging the notion of the “self-determining, unencumbered individual, a being connected to others only by choice.”27(p12) And political theorist Joan Tronto28 argued for developing an “ethic of care” that would recognize that “humans are not fully autonomous, but must always be understood in a condition of interdependence.”28(p162) She argued, “The moral question an ethic of care takes as central is not—What, if anything, do I (we) owe to others? But rather—How can I (we) best meet my (our) caring responsibilities?”28(p137)

Underlying all these visions is the belief that human existence is as much social as individual and that individual well-being depends to a significant degree on caring and equitable social relationships. Recognizing human interconnection broadens the moral focus of individual responsibility for one’s self and family to include shared responsibility for societal conditions. Without the glue of interconnection, in fact, egalitarian and humanitarian ideals can lack moral heft. Robertson,7 for example, based her proposed language of public health on the recognition of need. But to be effective in advancing public health, the notion of need must (as Robertson also suggested) be couched in terms of shared needs and reciprocity. It is less compelling to argue that autonomous individuals “should” help one another than to argue that our individual well-being is inescapably a product of the quality of our social relationships.28

There are instances in which public health professionals have effectively articulated this language of community to enhance population health. One example is the “reframing” of violence from being seen primarily as a criminal justice issue to being seen as a public health issue. For instance, over a 10-year period in California, the Violence Prevention Initiative engaged in a comprehensive, $70 million campaign to reduce the toll of handgun violence on youths. By highlighting the fact that handguns were the number 1 killer of young people in the state, emphasizing the role of social conditions in violence against youths, advancing specific public policies to reduce gun availability and increase violence prevention, and mobilizing citizen involvement to change “What’s Killing Our Kids,” the Violence Prevention Initiative helped to pass more than 300 local ordinances in 100 cities and counties and a dozen statewide laws limiting gun availability—and to secure an unprecedented increase in state funded violence prevention efforts.29,30 A significant factor in the campaign’s success was the resonance of its underlying moral messages: gun violence is not just the fault of young people’s behavior, but of social arrangements created by adults, and adults have a shared obligation to improve these arrangements for the benefit of all. When young people are killing young people, the campaign argued, it’s everyone’s problem, and the appropriate response stems from compassion for young people rather than the fear-based, punitive approach of tougher criminal penalties.

There are also signs that Americans’ understanding of interconnection is evolving in other policy areas in ways that may be of help to public health advocates. For example, many Americans use a cultural model of interdependency 31 to think and talk about the environment, a belief that species within ecosystems are interrelated and mutually dependent such that disturbances to one species will likely affect others. This model, which is now “widespread and thoroughly integrated into American culture,” draws on “core American values” that include a sense of obligation to our descendants.31(p61) It may provide resources for thinking about human interdependence as well.

Globalization may also be forcing Americans to come to grips with the reality of human interconnectedness. From the increased recognition that our inexpensive consumer goods may be produced by children working in foreign sweat shops to the new reality of diseases such as severe acute respiratory syndrome (SARS) that travel quickly around the globe, Americans may be less inclined to see their country as an island. Yet recognizing the pragmatic reality of interconnection does not necessarily lead to accepting the normative value of interconnection, a fact also exemplified in the public panic surrounding SARS and other communicable diseases. A challenge for public health advocates is to capitalize on increasing understanding of the interconnectedness of global health without simply fanning xenophobic fears.

Next Section: Conclusion

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