Perhaps no single public health method is more prevalent than epidemiology, which uses shoe-leather data collection and statistics to study the incidence and distribution of disease among populations. Epidemiology can be an incredibly powerful tool; this is what experts used to identify the first cases of community spread Covid-19 in the United States. However, it also exposes the downsides of a public health approach that sees itself as all science, no politics.
The epidemiological approach is often “characterized by a focus on factors isolated from their context,” wrote the late epidemiologist Steve Wing. He noticed that his colleagues often focused on identifying discrete “risk factors” that could be manipulated to improve health. But Wing argued that this logic often had dire consequences. Lung cancer has been used to point to individual smoking behavior (instead of the tobacco industry) and to blame poorer health outcomes for people of color on their behavior, what they eat, or how they seek medical care, rather than racial stress or poverty. .
Then, in the late 1990s, researchers formulated the “social determinants of health” to emphasize the importance of confounding factors, including access to education, quality health care, and a safe environment, to the health of communities. However, after 20 years, the revolution of social determinants has not arrived. While the benefits of stable employment, fresh food, and a good neighborhood—in short, the benefits of wealth—are more readily recognized, remarkably little has been done to reduce inequality in the United States. Instead, Americans double down on personal responsibility, the very antithesis of the oft-cited “public health thinking.”
The problem is not that public health officials want to focus their field on the study of individual health. In contrast, public health officials do not hold the purse strings and, even when they have some power over their communities, some refuse to use it for fear of backlash. As a result, our response to collective crises has been narrowly focused on what can be done, with little attention paid to what needs to be done. And what needs to be done, says Rafael, is the most difficult of all: redistributing power in our society.
A progressive approach to public health—one that doesn’t ask people to solve their own problems, but builds equitable systems that allow them to live better lives—is still at work in some parts of the world. Notably, these ideas flourish in nations with conservative or social democratic welfare states, as seen in central and northern Europe. None of these public health bureaucracies are perfect; among other limitations, they are often still capitalist at their core. But some local and national governments are at least willing to intervene on behalf of citizens.
That was once true in the United States, too, says Richard Hofrichter, former senior director of health equity for the National Association of County and City Health Officials. At the beginning of the 20th century, the country experienced a dramatic jump in life expectancy. While these improvements are, with good reason, attributed to public health interventions such as investment in sanitation infrastructure, Hofricher argues that the transformations were only possible because of larger progressive social movements. Reformers of this era reorganized society by eliminating child labor, establishing factory and housing codes, creating food safety inspection programs, and more. Health benefits came, although the benefits were still not equally distributed as racism remained entrenched.
