Among professionals in public health, the political system is commonly viewed as a subway's third rail: avoid touching it, lest you get burned. Yet it is this third rail that provides power to the train, and achieving public health goals depends on a sustained, constructive engagement between public health and political systems. This commentary outlines the importance of such engagement, and suggests ground rules that can help bridge the current divide.
Many of the top public health achievements have been achieved through such engagement, yet mutual suspicion and historically complex working relationships have led to immeasurable lost opportunities. Public health champions are quick to point to examples where “politics trumps science,” and politicians point to “overreach” by public health agencies and advocates.
Both sides would benefit from a new working relationship that puts suspicion and old habits in the past to generate opportunities to save lives and money.
Fundamental Philosophical Differences Drive Suspicion and Hamper Progress
Behind the history lies a fundamental lack of understanding of the motivations and imperatives that create a gulf between public health champions and political leaders. Some are unique to public health, whereas others mirror more general issues found at the contentious intersection of science and politics.
Public health is an evidence-based profession dedicated to improving health and preventing disease. The political process is how public policy decisions—laws, regulations, tax policies, and the allocation of scarce public resources—are made by elected officials.
Fundamental philosophical differences over the role of government provide an important backdrop to many public health policy debates. Many interventions employ the powers of government to ensure safety and improve health: these range across a continuum that spans the deployment of credible information, establishment of financial incentives, regulation of products or markets, and mandates or prohibitions of behaviors or commerce. However, for those favoring limited government, many interventions are viewed as government overreach—and therefore antithetical to personal or market-driven decision making.
Similarly, the appropriate roles of different levels of government have been the subject of heated argument since the drafting of the US Constitution: the recent rise of the “Tea Party” and focus on states' rights under the 10th Amendment are simply echoes of the 250-year-old Federalist Papers. Public health specifically, more than most policy areas, is an inherently intergovernmental enterprise: roles are built on police powers of state and local governments; interstate regulatory authority provided constitutionally to the federal government; federal responsibilities to protect borders (and thereby address cross-national disease threats); and the more ill-defined federal mandate to promote the general welfare. Sovereign states and empowered cities have always been laboratories for innovation and change that can lead to broader adoption of public health initiatives. The ambiguous and shifting nature of responsibilities in our federalist system provides opportunities for conflict between public health officials and politicians. Although many hold positions with deep roots in political philosophy, others may be perceived as opportunistic in using federalism as a lever to selectively advance positions, or as a shield against taking unpopular positions.
Public Health Decision Making: Driven by Science and Evidence
Public health is grounded principally in science, and on objective/rational consideration of the evidence. Scientists are puzzled when public policy decisions are made that do not rest principally on scientific evidence.
Public health champions value the prevention of premature death and disability, and achievement of measurable improvements in health status and resulting quality of life. Consequently, public health training emphasizes these imperatives over other factors that impact public decision making. For example, public health officials may advocate interventions that demonstrate positive outcomes on mortality, but are less likely to assess the broader economic and social impacts of interventions.
Public health advocates also fear that the voice of public health scientists will be suppressed or discounted in the political process, particularly when evidence conflicts with positions that are grounded in nonscientific considerations. They also fear that the science will be discounted when businesses or other “special interests” influence the political process. They often view these interests as working against the public good.
Political Decision Making: Driven by Multiple Factors
To achieve success, political figures must often consider elements that go beyond the science—and to the disappointment of public health advocates, may sometimes value these factors over scientific considerations.
Scientific evidence is important, but decision making in the political arena also incorporates a complex set of economic, ideological, and personal factors. The art of politics involves tradeoffs across competing values and influences, and political figures may not always place a higher value on objective or scientific evidence than on other inputs. For example, elected officials have strong incentives to incorporate business and other perspectives in their decision making, and also respond to evidence on economic impact, relationships, maintaining coalitions beyond an immediate issue, and other factors in addition to public health evidence. Political decision makers are puzzled when advocates dismiss the role of these other factors in decision making, and resent being portrayed as ideologues or uninformed when they take positions outside a scientific consensus.
Furthermore, many elected officials have limited training in science or public health. The language is unfamiliar, and evidence is often inaccessible. Public health approaches are often complex and multistaged, and cannot often be reduced to straightforward solutions or votes. Few decision makers have the tools to assess the health impact of decisions they make on a wide range of public policies.
Public health advocates often do not present their arguments in the same terms as others who seek political influence. Because advocacy is often based on what can be achieved for specific health measures (eg, increased life expectancy or reduced disease prevalence), credible evidence is often lacking on other factors such as economic return on investment. Elected officials often need tangible evidence of impact (and the distribution of benefits) across specific groups or communities, and often view the benefits of public health programs or approaches as diffuse or abstract.
Differences in time horizons can also result in different imperatives—public health agencies and advocacy organizations typically have continuity that transcends a single leader, whereas elected officials have defined (and typically shorter) terms. Many public health approaches take years or even a generation to achieve maximum results, whereas elected officials often favor tangible, short-term, visible outcomes overlaying the groundwork for gains that might be realized after their term of office. This is particularly an issue where elected officials need to make tradeoffs with nonhealth issues where the use of their political capital and public resources might achieve short-term gains. Public health agencies (and often the shorter term officials that lead them) typically take a longer view and have less short-term accountability to the electorate.
Different Drivers Set the Stage for Conflict
Given that these 2 fields often have very different goals in mind, each side anticipates conflict. Historically, public health officials avoided engagement with the political system, partly because of lack of training but also as a way to avoid the risk that comes with this conflict. Examples of conflict dominate and contribute to a perception in public health that engagement with the political system is to be avoided:
* Former Surgeons General have noted interference from political officials in their efforts to highlight health issues. Although the most visible of these involved Surgeon General C. Everett Koop and the AIDS epidemic, a 2007 hearing of the House Committee on Oversight and Government Affairs featured other examples from Surgeon General David Satcher, who noted the Clinton Administration's decision to oppose Federal funding for syringe exchange programs; and Richard Carmona, who cited restrictions placed on his funding and communications that limited his independence in speaking to the public about health issues.1
* Recent episodes of gun violence and calls for Federal response have highlighted long-standing Congressional constraints on Centers for Disease Control and Prevention research initiatives in this area, including a freeze on direct funding for gun violence research and a prohibition on using funds for gun control advocacy.
* Reproductive health issues (including guidance for sex education in schools, HIV prevention programs, and abortion-related issues) have been hot-button topics across administrations and congresses, reflecting deep differences regarding the role of government, religion, and privacy. Even collection of data bearing on these issues has been hotly contested at all levels of government.
* There is strong evidence that needle exchange programs are effective in preventing the spread of HIV, hepatitis, and other infectious diseases.2 However, philosophical differences over risk reduction initiatives have inhibited the widespread implementation of these programs. Federal funding for such programs is currently barred by conditions placed on appropriations bills.
* Corporate interests often engage in the political process to block public policies that are contrary to their business interests, or use campaign contributions to gain access to lawmakers. For example, the beverage industry mounted costly campaigns to defeat soda tax referenda in multiple jurisdictions,3 and there was significant opposition to federal programs that tackled obesity and tobacco.
* Climate change science continues to be challenged by both industry and political figures who oppose government interventions in markets.
Top Public Health Achievements Built Via Constructive Engagement With the Political System
Despite these challenges, many of the top public health achievements of the last 50 years are the product of public health officials constructively engaging the political system at federal, state, and local levels. Examples include:
* Many deadly childhood diseases have been virtually eliminated, and race differentials eliminated, through vaccination requirements for school-age children set by states and school districts, and public funding of vaccines for uninsured and underinsured children (the federal Vaccines for Children Program).4
* Second-hand tobacco smoke exposure has been significantly reduced as a health threat through action at the federal level (eg, banning cigarette machines in schools and banning smoking on commercial airplanes) and local level (smoke-free policies in bars, restaurants, and other indoor spaces), and more recently by public housing authorities and other entities.5
* Lead has been removed from paint and gasoline, resulting in a precipitous drop in blood lead levels in children.6 This has been accomplished using the interlocking authorities of all levels of government. The recent crisis in the Flint, Michigan, water system is at once a reminder of how much work remains to be done in this area, and also the extent to which public health science must inform policy decision making.
* Public mandates for seat belts and other motor vehicle safety and highway construction standards, based on injury prevention research, have resulted in significant declines in deaths from motor vehicle collisions.7
* Federal clean air, clean water, and toxic substances legislation in the 1970s and a subsequent generation of implementing regulations have reduced the burden of environmental toxins and their impact on human health.
* Food safety standards, and federal standardized labeling of food content and menu offerings have protected the public from foodborne illness and allowed more informed consumer dietary choices.
* Fluoridation of water supplies in jurisdictions across the United States has reduced tooth decay by 25% in children and adults.8
These initiatives often follow a pattern of experimentation (often at the local level, or through targeted research) that leads to evidence, adaptation, and potentially adoption in other jurisdictions or nationwide. Political officials in these early adopting jurisdictions frequently take risks by pursuing interventions in the absence of clear evidence, but the accumulation of evidence of success (and of favor with constituents) contributes to broader consensus and adoption.
What Is at Stake: Why We Need Sustained, Constructive Engagement
The political system is the vehicle through which public health officials can achieve population-wide and lasting systems change. And from a political perspective, the vitality and economic viability of any community is highly dependent on the health of the population and the effectiveness of its health systems.
Health is a key determinant of economic vitality in cities and towns across the United States. Sustaining economic development requires a workforce that is productive and has affordable health care costs. Employers cannot be expected to locate in communities that do not use all available public policy levers to create these conditions. In addition, the “health industry” is among the largest economic sectors, and health spending dominates the attention of elected officials at all levels. Elected officials have strong motivation to work constructively with public health officials to seek effective approaches that reduce costs and enhance health outcomes.
Elected leaders are ultimately responsible for sustaining and improving the health of the governed, and to maximize success they need a strong partnership with public health officials. There is evidence that the public expects politicians to engage in such constructive pursuits: first, the public supports broader public investment in prevention and public health9; second, polling indicates that the public expects elected officials to listen to science, and for scientists to engage with the public and policy makers.10
Public health officials cannot simply ignore the political system because in reality nearly all governmental public health activity is based on authority and funding that is provided through a political decision-making process, usually through enactment of legislation. The ability of federal, state, and local public health officials to regulate, implement programs, spend public money, or receive private funding through user fees or other means is derived through a political process. Furthermore, the aspiration of public health officials to influence policies that impact health—such as housing, transportation, and other social and economic determinants—will continue to rely on decision making by legislators and other elected officials, many of them who do not consider themselves connected to the health system.
New Ground Rules for Effective Engagement
It is past time for a rethinking of the ground rules of the tenuous relationship between public health and politics. Government is likely to remain divided along partisan, geographic, and philosophical lines; because we are essentially in a permanent election cycle, we need new approaches to foster a constructive dialog that respects the role of politics but enables effective evidence-based decision making. These can start with a recognition of basic realities:
* Public health officials and advocates need to recognize the role of political and ideological factors in public policy decisions, and adapt advocacy strategies so that these factors are leveraged or neutralized.
* Policy makers and elected officials, meanwhile, ignore public health at their own peril: as with a breakdown of snow removal, a poorly handled health emergency undermines confidence in leadership, and a community in decline because of poor productivity and high health care costs undermines economic development and public budgets.
* Both elected and public health officials can recognize that properly framed public health interventions are popular, can save money and lives, and create legacies for both elected and public health officials.
Both need to find new ways to engage in a constructive dialog that can lead to more sustainable public health policies and programs. For example, public health advocates who are predisposed to government action can benefit from also exploring how markets and the private sector can advance population health objectives, thereby gaining potential allies for important initiatives. Elected officials can explore how more robust data and evidence can help them improve the performance of government, lower costs, and benefit constituents, and in the process, their electoral prospects.
Public health officials can (see Figure):
* Understand nonscientific factors in public policy decision making. Present evidence and science-based recommendations while being sensitive to other factors that influence decision making (including political ideology, religious beliefs, and the self-preservation instincts of elected officials). Science can call attention to issues, frame a public debate, outline solutions, and stimulate action; public health officials should recognize that incorporating other perspectives can help craft more achievable outcomes, and strengthen arguments that advance public health positions.
* Avoid partisanship. Emphasize the long bipartisan tradition in addressing most public health issues, and recognize that bipartisan support has been key to advancing most significant public health policies of the past generation.
* Present the evidence fairly. Produce unbiased, impartial data, research, and evidence—and avoid the reality or appearance of selectively highlighting evidence to support a predetermined position. Overstatement in pursuit of public health positions rests on the same flawed logic that ideologues use to deny the legitimacy of science. Advocates that stretch beyond the evidence surrender the moral high ground that gives them credibility.
* Be forthcoming about value judgments. Describe the values that underpin public health recommendations, particularly in cases where evidence is limited. For example, public health professionals often favor action where there is a plausible but unproven health risk, rather than waiting for certainty before taking steps to protect the population. Following this “precautionary principle” is consistent with public health values, but may seem inconsistent with “following the evidence” unless fully explained.
* Choose the right battles. Make strategic choices on which battles to fight, at what time, and at what level of government. Political capital is as scarce as financial resources—and needs to be allocated carefully, as the political system can only focus on a few issues at a time. In many instances, an agenda is moved forward by staking out clear positions that can help generate political will, but there are also cases where selectivity and compromise will achieve goals and build momentum toward other goals. Engaging allies with political sophistication should be an important element of any public health advocacy effort.
* Choose the right messengers. Recognize the unique roles of different messengers in presenting and advocating public health initiatives. Public health leaders working in government have both legal and practical constraints, and need to be mindful of the sustainability of the agencies they lead if they take provocative positions—so it is unproductive to place the full burden of communicating about the importance of public health on government officials. Nongovernment officials (nonprofits, academics, foundations) have more freedom, but often less standing. Importantly, nontraditional messengers can be effective communicators—for example, leaders in the business community, or clinicians or health systems leaders in the community. Finding the right messenger contributes to advancing public health's agenda, but also allows others in the public health system to effectively consolidate gains and sustain programs for the long term.
* Sharpen policy-relevant analytic skills. Develop and apply stronger analytic skills in the policy arena, to more fully evaluate alternative solutions to public health problems. In particular, exploring the role of incentives, market forces, partnerships, and other approaches as an alternative to direct government action may be key to advancing solutions in jurisdictions where limited government is a preeminent political value.
* Make public health relevant to real-world decisions. Provide information relevant to real-world decision making by elected officials, including economic and other implications of proposed public health measures.
Elected officials can:
* Recognize science as relevant, even if not determinative. Acknowledge that scientific evidence is relevant to key public decisions, even if it is in conflict with deeply held views. Elected officials do not need to embrace evidence as the only factor in decision making, but should not dismiss its relevance to the debate.
* Let science be science. Avoid the reality or appearance of undermining the development and release of evidence that is developed in an unbiased and impartial manner, particularly evidence that is developed with public funding. Free access to information that bears on a policy debate is a core principle of fair and open government, and facilitates both the policy and scientific process by allowing for refutation or replication of research results.
* Be transparent about nonscientific influences. Disclose campaign contributions and other ties to individuals and corporations that may influence decisions.
* Engage public health officials in a search for solutions. Rather than waiting for public health advocates to bring proposals to them, elected officials can proactively engage public health officials for alternative ways to address problems that they identify. In this way public health officials can be engaged in real-world problem solving for elected officials, bring evidence to bear on alternative solutions, and help inform decision making within parameters set by elected officials.
Advancing this dialog is also a responsibility shared by others. For example, the media and the public need to think past the latest outbreak scare and encourage both health officials and politicians to ensure that the infrastructure is there to be prepared for the next health event, as well as for improving community health. The media can help by focusing attention on key public policy decisions and the dynamics (both scientific and political) that drive them. Similarly, educators can inject public health into core curricula at multiple levels of education. As an example, public health policy can be a critical component in civics curriculum—as it makes for more discerning voters, provides case examples on the roles of government, and illuminates intergovernmental issues inherent in our federalist system. Academic institutions can introduce practical considerations into science courses. For example, food safety is a practical application of biology, and regulation of environmental toxins is a practical application of chemistry. And finally, philanthropy can aid the search for constructive policy solutions that bridge the gap between science and politics.
Working together, public health officials and political actors can build confidence by seeking shared goals and inclusive processes to examine alternative policy solutions. Resurrecting the art of compromise, they can seek common ground on issues that are in the public interest. Public health officials should not avoid the third rail—they can safely connect with it, and help empower communities to improve the public's health.