Ten Ways to ‘Keep the Public in Public Health’

We have to address the ways that we make public health elitist and how that limits who can contribute to this work.

I saw a t-shirt at this year’s APHA conference that read, “Keep the Public in Public Health.” Without child care and other services, we can be sure that the public (i.e. populations most affected) won’t make it to the table of public health discourse or leadership. Shutterstock

This piece is published in collaboration with Echoing Ida, a Forward Together project.

Public health is the leading field for addressing health challenges in our country and ultimately the world. Nurses, doctors, midwives, medical assistants, activists, advocates, researchers, and policy makers are directly involved in, or turn to, public health work—which includes but is not limited to research, disease prevention, and community education to improve health across populations.

Public health work affects federal and state law to improve conditions and help shape how we define threats to health. It guides how people and organizations think about and respond to health issues. A current example of public health work is the growing response to what we understand as the “opioid crisis.” How this issue is defined, positioned, and addressed by medical providers, law enforcement, social service organizations, government, and even you, is directly affected by public health work. Public health defines and substantiates best medical practices and community interventions.

The social determinants of health, which are the everyday conditions (housing, economics, education, access to food, and so on) that affect people’s health and lives, are a priority in this field and becoming more and more commonly discussed and considered across professional disciplines. But something is missing in this industry when it comes to addressing health disparities and the diseases that disproportionately affect people of color and marginalized people, and that was evident at this year’s American Public Health Association (APHA) conference, which drew approximately 12,000 people. The organization boasts an annual membership of 25,000.

As someone who has worked in the field of public health for over 20 years and observed the ways in which the field struggles to purposely center the leadership and innovation coming from marginalized groups and people of color—who have the worst health outcomes in this country— I know that if equity is not an instinct yet among public health professionals, then a framework that ensures it must be.
Here are ten things that could help to change the way that public health in the United States is framed and implemented. Although there are parts of this list that are for conference organizers specifically, any public health professional and student, along with decision makers in general who are seeking to center marginalized groups in their field, can benefit from rethinking how they involve communities in their work more effectively.

1. Cross-Cultural Professional Dialogue: Public health discourse often occurs in rooms that are largely culturally and ethically homogenous. At the most recent APHA conference, I attended several workshops led by African American/Black women, where the audience was all or predominantly Black. While it’s a wonderful thing to support the work emerging within our own cultural background, it’s not a good thing when we are the only ones listening to each other. If public health wants to solve the problem of health disparities, we are going to have to start listening to the people most affected by the problems we are working to resolve, and when they are colleagues doing research and reporting on interventions, we are going to need to make sure that we prioritize their voices, particularly if we are white. The work emerging from public health professionals who are members of marginalized communities must be intentionally amplified, given that they are the only people in the field who bring both academic and lived experience to the discourse simultaneously.

2. Children and Child Care: Work that centers on community health and well-being must involve children by including on-site child care to consistently allow families to take advantage of services, education, and community-building spaces instead of excluding people because they need to bring their children with them. In any U.S. state, 4-11 percent of households are led by single mothers and 42-65 percent of single parents are Latino, Native American, or Black. Given the disproportionate effect of health disparities on women of color (including higher rates of obesity, breast cancer, infant and maternal mortality, diabetes, and heart disease), public health should be doing everything it can to have them at our table as participants and experts in these critical conversations.

3. Transparency: Transparency in public health would debunk the myth that communities don’t know how to define or address their health-related risks and needs. At an intuitive (and experiential) level, communities know what ails them and makes them sick. The reciprocity, between communities and professionals, that is often missing in health care and public health is the acknowledgment that “whatever the problem, the answer is community.” If we lean into this framework, the new question will be: what to this answer, is the role of public health?

4. Research by Community Members as Opposed to on Communities: Related to #3, in the last decade or more, community-based participatory research (CBPR) has become a popular goal. CBPR is “an approach to research that seeks equitable and collaborative involvement of community members in all aspects of the research process.” However, when community members aren’t being trained and paid to lead and implement research efforts or to design programs for intervention, how participatory is the effort? CBPR often seeks ways to visit communities to gather data on them to learn how best to meet their needs, but in order to be participatory it must also empower community members through capacity building and paid leadership opportunities to define their own health needs and interventions.

5. A Commitment to Ending Police Violence: Studies now show what communities have known forever: Police violence threatens community well-being and contributes to poor health outcomes. But at the American Public Health Association’s conference this month, its Governing Council voted not to pass a policy statement “addressing law enforcement violence as a public health issue.” Denying what communities say causes them stress and threatens their well-being does not promote and protect the health of people and the communities where they live, learn, work, and play.

6. Translation Services for Presenters: In order to diversify public health discourse to ensure that a range of professional and community health advocates are able to share their data, lived experience, and suggested interventions, translation services for presenters and audience members must be a cornerstone of public health work. When we require people whose primary language isn’t English to speak and understand English in order to have a seat at the public health discourse table, we severely limit not only who can participate but also the important nuances of language and storytelling that get lost in translation.

7. Language That Doesn’t Pathologize: For the most part, as a culture, we do not know how to talk about people who don’t look or live like us in a way that doesn’t negatively judge their choices and consistently re-insult their group. Language like “these people” or “those women” as opposed to “the people in our program” or “the women in our community” affect not only the information being delivered but also the way it’s being heard by your audience. Using intentionally kind, humanizing, and inclusive language is one of the ways that we can avoid polarizing and pathologizing communities.

8. Always Ground Data and Interventions in Historic and Cultural Context: As a field, public health does not require researchers and practitioners to talk about or address health disparities and health outcomes in relationship to what was happening in (or to) marginalized communities multigenerationally. Although the field has evolved to acknowledge health disparities and social determinants of health, this failure to ground our studies, presentations, and findings in the historical context that communities with the highest health disparity rates have contended with over generations, results in our research and interventions being deeply flawed and inherently racist, intended or not. An example of this is in our approach to and framing of the breastfeeding disparity rates between Black and white mothers in the United States. In the absence of a historic and cultural context of Black women breastfeeding in America, it’s easy to focus on the disparity rates but impossible to address them or acknowledge the community’s strengths. The health needs that people have do not occur in a vacuum; they always occur within a cultural and historical context.

9. Lived Experience: Who better to articulate a life than the person living it? Lived experience ensures that the details that will be noted and recounted are prioritized based on experience, not theory, and that the stories that are told come from primary sources. In order for public health to shift from an ivory tower or missionary model to one that centers equity lived experience must begin to hold as much weight as academic training, and the voices of people who bring both sets of knowledge to the table must be amplified.

10. Have the People Most Affected at the Table: I saw a t-shirt at this year’s APHA conference that read, “Keep the public in public health.” Without child care, translation services, cross-cultural professional dialogue, non-pathologizing language, and the amplification of community members and professionals with lived experience, we can be sure that the public (i.e. populations most affected) won’t make it to the table of public health discourse or leadership. In order to have the public present, we have to address the ways that we make public health elitist and how that limits who can contribute to this work. It’s not enough to say “equity”; our practices and frameworks must ensure it.

If public health professionals, curricula, and leading associations and organizations are willing to include what’s missing in our framework, we may actually be able to partner with communities in ways that permanently improve the conditions that we are charged with addressing. Shifting our framework will help address these problems by disrupting the conditions—including our own biases—that perpetuate them.