Uplifting and Not Ceding Ground on Health Equity Practice Is Critical to Strengthening Public Health and the Health of the Nation

Public health science gains in the last quarter century in the United States have been formidable due to a focus on structural and social determinants of health, thereby enhancing understanding of the role of inequitable policies in shaping health inequities and inequitable access to ameliorative resources. This progress is demonstrated in the National Institutes of Health’s multi-level framework of health and health inequities that guides medical and public health professionals nationwide. Scientific advances provide deep insight into how health care systems, jointly with educational and economic systems, impact health outcomes. However, the progress of public health science is being buried by an anti-science administration and a divided public health and medical workforce with extraordinary enthusiasm for technological innovation as an improvement in quality of care. The public health and medical disciplines are in a free fall of discontent with pressures of technology on clinical training in medicine and public health practice and policy, and consumer and professional concerns about the dehumanization and corporatization of medicine.

Leading the world in health care spending, with almost one-fifth of its GDP allocated to health care expenses, the US reports the lowest life expectancy rates and highest chronic condition rates compared with other high-income nations. This persistent paradox is largely driven by inadequate implementation of prevention approaches and enduring social and economic inequities that adversely affect population health. These health inequities are neither new nor diminishing. Rather, they represent a strong institutional interweaving at the intersections of medicine, pharmaceuticals, and technology.

Most concerning is that the national population health approach has failed to capture the imagination of the American public. Rather, the medical and pharmaceutical industries that provide secondary and tertiary care have been the major designers and beneficiaries of health care technological advances. Technology in the 21st century has arisen to provide miracle cures and extension of life in tertiary care, wiping out progress in addressing equity and social determinants to improve health throughout the life course for the majority of the population. New technological advances are driven by and benefit the upper echelon populations of society who have access to and can afford precision medicine and experimental and well-tested technologies. Although artificial intelligence (AI) and other machine-driven technologies may be helpful for some, they are driving up the cost of an already expensive tertiary care-driven health care system.

In these times, what then is the role of public health in promoting population health? Public health is charged with promoting the health of the population, with a focus on the most vulnerable to health risks, both biologically (e.g., children, elders, pregnant people, people with pre-existing conditions) and structurally (e.g., economically disadvantaged communities). It does so by monitoring the health of the population, setting goals and guidelines, and directing resources to promote population health and reduce health inequities. One year since the beginning of Trump’s second Presidential term, the field of academic and practice-based public health is crumbling at an unprecedented pace. Federal policymakers and agency leaders (e.g., Health and Human Services, National Institutes of Health, Environmental Protection Agency) are rapidly undoing historical public health and health equity policy achievements and eliminating or preventing the increase of the highly skilled and inclusive workforce critical to protecting population health.

Public health scholarship has responded by paying more attention to community priorities, by addressing the social determinants of health, and by being the conscience of health in the community. Currently, the Make America Healthy Again (MAHA) slogan (predominantly advanced by white, economically privileged mothers) succinctly speaks to a demand for policies and systems that promote the health of children, with a focus on preventing chronic diseases and environmental toxicant exposures, while relaxing vaccine standards. Yet, the current administration’s policies such as relaxing of EPA standards and reducing access to nutritional assistance programs undermine children’s health. Simultaneously, highly segregated urban and rural and historically and economically disadvantaged communities bear the greatest burden of chronic disease risk, exposure to toxicants, and barriers to vaccine access, with inequities in life expectancy relative to their wealthier and white counterparts, respectively.

The rapid disintegration of public health practice reflects diminishing public trust in public health, which has been years in the making. This loss of trust in public health is, in part, because the large body of public health science has not been translated or applied in ways that directly benefit the population. Public health scholars and practitioners have long lamented that it often takes 17 years for scientific advancements to reach the population — a timeframe that is wholly inadequate to address the public health challenges of our times. In contrast, new treatments for conditions such as Alzheimer’s dementia — accessible mainly to the insured elderly population — have advanced more quickly, yet have not met the same timelines required for achieving effectiveness in amelioration of conditions. In contrast, new treatments for other health issues such as sickle cell anemia, Black maternal mortality, and men’s contraception are characterized by limited advancement and slow innovation. Differential standards, access to quality products, and structural and social determinants of health across the life course are being compromised for all Americans.

Since the 1980s, we have witnessed the rise in ultraprocessed foods and the publication of more than 1 million articles documenting economic, built environment, and social barriers to accessing nourishing foods and engaging in physical activity and recreational activities. However, policies by the present administration that endorse the MAHA slogan are not addressing the nutritional and economic needs of our country, such as the cost of food and the broken policies and structures that disproportionately affect low-income communities. It is time that we stop deceiving the American public with words and slogans that do not do what they say or say what they mean.

Although efforts to protect and promote public health have experienced backlash from the public and governmental structures in the past, a variety of strategies have been developed to create a healthier national landscape, for example: raising awareness of the individual and population health benefits of public health measures (e.g., vaccine schedules); creating state-based work-arounds to the federal weakening of public health infrastructure; advocating for the protection of subsidized nutrition and health insurance for low-income communities; and deepening and expanding power amongst the academic public health and medical primary care workforce. These strategies often address the public health crisis of the moment, inconsistently center health equity, and have yet to collectively mobilize the medical, academic, and practice-based public health workforce. We argue that the academic public health workforce needs to take a strong, well-organized approach to designing and fighting for the future of public health, equity, and science.

Uplifting, and not ceding, ground on a health equity agenda is critical to strengthening public health and the health of the nation. What does public health have to offer now, in this time of crisis? How does public health reconstruct itself? Now, more than ever, we must embrace a new model of translational research that shifts the collective academic public health approach from that of “armchair” public health, advancing research questions that are distanced from community experiences in real time, toward a predominant focus on public health research for action. We cannot let the progress of public health knowledge and practice related to health equity, social determinants of health, and quality of care recede.

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