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March 2018 (Volume 96)
The production of population health is inextricably linked to the social, economic, and cultural forces that shape the world around us. The United States’ limited investment in these forces—as compared with our overspending in medical curative care—is in part responsible for our having worse health indicators than nearly all our peer high-income countries.
The mismatch between what produces health and what we focus on in our effort to generate better health1 is one of the core challenges we face if we are to improve the health of the American population. An obvious example of this issue is the public American health conversation that has been, for a decade, largely consumed by discussions around health coverage leading up to the Affordable Care Act (ACA), its subsequent implementation, and most recently its attempted repeal and claw back by the current administration. While there is little question that the ACA was a long-needed step forward—as demonstrated by its providing health insurance coverage for 20 million more Americans—it does little to tackle the country’s poor health indicators.
How do we then address this mismatch? Clearly science plays a part; population health scholars can assemble and publish data that can inform action on the forces that do generate health in populations.2
However, data alone are never going to be enough; a wholesale change in our national health conversation seems to be needed. How then can we achieve such a change in the national health conversation? Here are two potential answers.
Nurture a New Generation of Storytellers
First, a new health conversation requires compelling health narratives to complement and balance the prevalent medical narratives that dominate journalism and scholarship. Leading narrative voices, many of whom are physicians, write about the heroism—and sometimes the travails—of medicine in a way that is familiar to anyone who has dealt with a physician at some point in their lives. This emphasis on personal health services has entrenched the centrality of medicine in any discussion about health. It is hard to see a shift in the national conversation about health without some balance in these narratives to include clear voices making the case, for example, for the link between housing and health, livable wages and health equity, and spatial residential segregation and access to the resources that promote health.
These narratives have lagged behind for 3 reasons. One, medical narratives are easier to tell; the connection between the individual actions of the physician ministering to a single patient are easy to draw and ready-made for character development that makes for easy reading or storytelling in any medium. Two, physicians have been the leading voices on health for decades in the United States. They have been telling the stories that are familiar to them, presenting a medicalized lens of health that has become normative. Three, in the current American system, those whose work addresses the foundational drivers that shape population health often do not see their work as related to health, and thus have not been part of public conversations about improving it. For example, popular books that deal with the epidemic of foreclosure, eviction, and unstable housing,3 or with residential segregation,4 seldom mention health. This is equally, if not more true, of visual media, where the line between foundational forces and health is seldom if ever drawn, while medical narratives that focus on physicians intersecting with patients are commonplace.
To address these three interacting forces, it is urgent to engage a new generation of storytellers who understand the importance of foundational drivers and their linkage to health. The emergence of such storytellers may happen without additional intervention, but it may also require investments by foundations interested in the production of health. These investments could seed authors and artists who can identify ways to tell the story of health that are now invisible to the general population.
Understand, Engage, and Shape Dominant National Narratives
Second, a new health conversation requires that population health scholars relentlessly challenge false dominant narratives that distract us from addressing persistent obstacles to improving population health. National narratives about firearms are an example in point. Although approximately 34,000 Americans have died from firearms annually since 2000 and national inattention to these data is punctuated intermittently by horrifying acts of mass violence, no federal legislation has been enacted to reduce this threat to population health.
Two narrative threads dominate the firearm public discussion. First, general public acceptance of the firearm epidemic rests on apparently unshakeable public support for a constitutional right to individual gun ownership. This narrative is false because it is inattentive to the history of firearms. The interpretation of the Second Amendment as giving everyone an individual right to bear arms traces back to the Supreme Court decision in District of Columbia v Heller in 2008, a decision that was split 5-4 along ideological lines that upended decades of our understanding of the role of Second Amendment in modern life.5 Far from being a deeply entrenched position, the supremacy of the Second Amendment in the national debate was largely manufactured by special interests, and should be challenged more forcefully in the national conversation about risks to health from firearms. Second, the story that there is no public appetite for “gun control” is false. Although a majority of Americans have told many pollsters that they are against gun control, other polls show clear and overwhelming public support, among both gun owners and non–gun owners, for measures such as background checks for all gun buyers, especially for private sales and at gun shows, and other measures to control the unchecked flow of firearms.
The national narrative on firearms, and the evidence about the commercial interests behind this narrative, suggests an important role for population health scholarship to call out false narratives when we see them and to push back on emerging story lines that limit reckoning with the evidence. Unfortunately, this will not come easily and will require scholars both to understand more clearly the forces informing public conversation and to embrace a role in helping systematically inform this conversation.
A Way Forward
National narratives contribute to the social, cultural, and economic factors that ultimately shape population health. It is untenable for population health scholarship to remain silent as those narratives are shaped by others, contributing to national underachievement in health status. Changing this will require a generation of storytellers who can elevate the narrative of population health. Further, these storytellers must include population health scholars who understand and counter false narratives that misdirect policy and politics.
Sandro Galea, MD, DrPH, a physician and an epidemiologist, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. Galea’s scholarship has been at the intersection of social and psychiatric epidemiology with a focus on the behavioral health consequences of trauma. He has published more than 700 scientific journal articles, 50 chapters, and 13 books, and his research has been featured extensively in current periodicals and newspapers. His latest book, Healthier: Fifty Thoughts on the Foundations of Population Health was published by Oxford University Press in 2017. Galea holds a medical degree from the University of Toronto and graduate degrees from Harvard University and Columbia University. He also holds an honorary doctorate from the University of Glasgow.
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