Epidemiology, Public Health, and Public Policy

I left the Centers for Disease Control and Prevention (CDC) more than 4 years ago to go to the Robert Wood Johnson Foundation (RWJF). RWJF had gone through a time of substantial rethinking about its role in society and come to the conclusion that the focus should not be grantmaking; it should be creating social change for health. This could just as easily be said about public health — creating societal change to improve the health of the public. At its core, public policy is the way a society frames what it wishes to become. Does it want all children immunized? Does it want to limit the use of tobacco? Policy doesn't have to be federal legislation or regulation; it can be corporate or local or state. But an organization, a field, or groups that are about social change will find they are often about influencing public policy. How does this fit with epidemiology and its history, and the history of CDC? It is unlikely that John Snow would be revered in public health if he had merely studied cholera. His defining moment was when he removed the pump handle from the contaminated well that was the source of the epidemic. That intervention is honored with an award called the Pump Handle Award that is given by the Council of State and Territorial Epidemiologists. Our heroes have been tied to action. In 1983, giving the Wade Hampton Frost Lecture at the American Public Health Association meeting, Bill Foege, former CDC director, coined the term consequential epidemiology. Foege was taking sides in an active debate of the time by saying that epidemiology "is a tool to change the world, not merely to study the world" (unpublished material, 1983). The debate that Foege was speaking to was whether epidemiologists should engage in the political process. Should they advocate solutions about what should happen based on the science or merely do the science and let the advocates and policy makers use the science? Some people said that scientists would lose their objectivity if they took on this more activist role. This discussion has come back, quite strongly, in recent times in the context of the politicization of science. Politics and public policy can be tough business, especially recently. Bill Foege was of a very different opinion. It was his conviction that public health was inherently political, inescapably political. Foege argued that public health work occurs in a political context and that, divorced from that context, our science is stillborn, a missed opportunity. To pretend otherwise is self-delusion and a failure of vision and responsibility. The purpose of this essay is to reaffirm that connection to activism. I state this not despite recent concerns about politicization of science but because of them. We must embrace both 1) activism and commitment to social change as central to public health, and 2) the central purpose of epidemiologic science, which is to find, assess, and confirm truth, regardless of past findings or beliefs. These are different roles, and the space between them is where the real excitement is. Actions are being taken based on the science as it is known today, but the actions will change as the science advances. We are entering a period of economic pressure that is likely to change the nature of America's medical care, the largest industry in our nation. We now spend about twice as much as other developed countries per capita per year. Despite the importance of biological science as the basis for improvements in diagnosis and therapy, it is impossible to think of major changes in the medical care system that will not play out in public policy changes. The public's health and the societal factors that affect health span a much greater proportion of our economy and our society than even medical care does. This means that public health will have to address issues that have political implications. Yet the science behind what can be done does not mean it will be done. Our policy makers and the public have not been nearly as committed to the understanding that how our society is organized, what our policies foster or inhibit, what our communities encourage and our institutions support are fundamental causes of good or ill health, just like biological causes, and they warrant study and action. If societal forces are not in alignment, scientific advances stall, and the value realized is a meager fraction of its potential. Scientific understanding about any disease that is not widely applied to people in need is ultimately wasted. Similarly, widespread application of practices and policies that have no scientific evidence of effectiveness are just as futile. Scientific discovery and widespread application must never be separated. This is a defining tension for all of public health. Scientists never feel they know enough to act. Practitioners and activists say the health problems are so significant we must act now; we can't wait for the science to be finalized. Both are right. Organizations only responsible for research will worry less about whether the findings are widely applied or are feasible and practical. Organizations only responsible for programs will likely hold to outmoded ways that are ineffective if their staff and clients like the program. Managed well, the combined responsibilities make both science and program better.