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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.

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.

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)

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.

Conclusion

Developing the language of interconnection is crucial because once the moral focus is broadened, the definition of and response to public health problems can expand. As a moral and conceptual lens on the world, individualism restricts the range of public understanding, oversimplifying complex and multifaceted problems, boiling them down to their individual roots while leaving social responsibility and collective action largely out of the picture. Although personal responsibility is undeniably a key to health, so are a range of social conditions that are shaped not just by our individual choices, but by our collective choices manifest in public policy.

Accepting C. Wright Mill’s32 challenge to “continually...translate personal troubles into public issues,”32(p187) public health advocates can help the public to see the causal connections between their own well being and that of others. All humans have needs that others must help them to meet, especially in the complex social, economic, and political systems of today. A society that accepts the reality of human interconnection and effectively structures itself so that egalitarian and humanitarian values are more fully reflected in public policy will be a society that better understands the meaning of public health and responds more appropriately to its challenges. It will be a society that not only talks about community but translates its values into caring—and more effective—public policy.

Lawrence Wallack is with the College of Urban and Public Affairs, Portland State University, Portland, Ore. Regina G. Lawrence is with the Hatfield School of Government at Portland State University.

This article first appeared in the American Journal of Public Health. Requests for reprints should be directed to Regina Lawrence at lawrencer@pdx.edu.

Acknowledgements and References

Acknowledgments

Work on this article was partly supported by a Robert Wood Johnson Foundation Innovator’s Award to Lawrence Wallack. Also, the authors express their appreciation to Dan Beauchamp and to Richard Hofrichter, who reviewed an early version of this article and provided important guidance, and to the anonymous reviewers.

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