Take time to think: are you focusing your efforts to achieve public policy goals in the right place?

So much that I’ve learned, I learned from conversations with taxi drivers. The following exchange took place in Georgetown, Guyana’s capital. The same driver had driven me to the Ministry of Health four days running, and our conversation had broadened and deepened a bit.

 

 Taxi driver: So, what was it you said you are doing here in Georgetown again?

Me: Working to identify actions and develop plans to strengthen your health system.

Taxi driver: (quizzical look in rearview mirror)

Me: We want to find ways to improve people’s health, and figure out which ones to pursue and how. And then…make that happen.

Taxi driver: Uh huh. So, why do you spend all your time talking to those folks (nod in general direction of Ministry of Health building)?

Me: ummmm.

 

I eventually came up with some reply, no doubt. But the effort to do so got me thinking about how we health policy folks make decisions about where we focus our attention and efforts. And, I realized that we often do so unthinkingly. We go where we go by habit as much as anything. Yet, over the years, I’ve learned that where you focus your attention and effort is a critically important decision.

 

I was reminded of this when I read this recent editorial Public Health Policies: Go Local! by David Bishai, Shannon Frattaroli, and Keshia M. Pollack, in the American Journal of Public Health, arguing that the US public health community should do just such a rethink. Currently, they focus the majority of their attention on the nation level. Yet,

the bulk of the money and the decisions that drive the health of the public

remain in the hands and wallets of the people and their local communities.

They note that local public health policies can make profound contributions to most of the health goals we pursue, including goals to reduce health disparities. And, these efforts can make progress even in the face of gridlock and political dysfunction on the national level.

As my Guyanan taxi driver could likely have told you:

Most of what keeps populations healthy happens in their homes, cars, communities, schools, and workplaces.

And:

What makes people sick are ideas, behaviors, chemicals, physical energy, and microbes that get close enough to penetrate the body. If you got a cold this year, you got it from somebody in the same room. Whiplash? The shockwave came from a bumper a few feet away. Hangover? Your friends may have poured and clinked the glass that gave it to you.

And, local and city policies and community level efforts can strongly influence these things. In fact,

(P)ublic health is also practiced by workplaces, neighborhood associations, schools, hospitals, health insurers, and many others with resources of time, money, and energy that dwarf national budgets for public health.

If you need more convincing of the virtues of focusing attention on the local level, Bishai et al point out that some US communities achieve outcomes rivaling those of world leaders (I’m looking at you Japan and Singapore). These outcomes depend on many factors besides public health and community efforts of course; nevertheless, spreading what nation-leading communities are doing with their public health spending, policies and activities could go a long way to closing those gaps.

What is known and practiced in the best-performing communities must be spread throughout the country.

Given that these efforts are not hamstrung by dysfunction in the national level political apparatus, I could not agree more with Bishai et al’s closing plea:

A renewed emphasis of the public health community on local action is long overdue.

I highly recommend you read the editorial; it is, alas, gated. I’m happy to email it to you.

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