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October 29, 2020
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It is not difficult to feel, these days, that we are living in revolutionary times that demand a re-ordering of the status quo and a re-thinking of how we structure our world. 2020 brought with it a novel coronavirus pandemic that, as of this writing, has claimed more than a million lives worldwide. COVID-19 itself, and efforts to contain its spread, brought about a collapse of much of the world’s economy, triggering a recession of substantially deeper scope than any since World War II, the global effects of which remain to be fully appreciated. And, perhaps centrally, the consequences of COVID-19 and the economic recession have not been evenly felt, with their burden falling disproportionately on persons of color and persons with fewer socioeconomic resources, occasioning civil unrest that rivals any the country has gone through in the past 50 years. Living through the COVID-19 moment suggests indeed that much is awry with the world, that transformative change is needed to move us to a better place, and that the turbulence of the moment may provide a once-in-a-generation opportunity to bring about such a change.
Health, and the sharply felt divides etched in it, has been at the heart of 2020’s storm. The pandemic has served as a powerful reminder of two long-ignored, yet fundamental, realities. Health is shaped by inequity, and poor health anywhere is a threat to health everywhere. It seems appropriate, therefore, to think of health as a catalyst for necessary transformations, for the creation of a world that is resilient to future pandemics, and one that apportions assets in such a way that the disproportionate burden of poor health does not accrue to a few groups, and that all have the opportunity to aspire to, and fairly achieve, a richly realized life, free of unnecessary and preventable illness.
We can perhaps take the argument a step further and suggest that it is our responsibility in public health to see the opportunity in the moment, that anything short of seeing the moment as an opportunity for transformation makes us complicit in the structures that hold back achievement of a healthier world. This calls for public health to engage forthwith in the project of creating such a world, envisioning it, and helping to bring it to fruition. Such an engagement would build on a pre-COVID growing conversation ongoing in modern public health. The past few years have seen many calls for a re-imagining of public health to embrace a forward looking and aspirational agenda, one that sees as its role the creation of the structures that generate health, and an engagement in creating the systems and structures—like safe housing, good schools, livable wages, gender equity, clean air, drinkable water, a fair economy—that foster health in populations., This thinking—re-anchoring public health in some of the earliest conceptions of the field as inextricably linked to the cause of social justice—is well in line with the sentiment of the moment, and positions public health well to be a catalyst and also a participant in the currents of 2020 and beyond. This surfaces then not questions about our commitment or intent, but questions of vision and execution. Simply put: What sort of world should public health help us aspire towards, and how do we get there?
This is where we have, in the past year, been far less clear as a field, and where clarity about the scope of our radical vision, and the approaches we can take to get there, would serve us well. Public health is fundamentally concerned with collective action that can generate health, which, by extension, must involve the creation of structures that generate, rather than hinder, health. We should make no mistake about it: It is a radical vision, one that departs from the more recent understanding of a public health grounded in core functions of assessment, policy development, and assurance. This approach envisions a substantial expansion of engagement for public health, where public health recognizes that it cannot achieve its core purpose without engaging in sectors such as housing, finance, transportation, and education to bring about its aspirations of creating a healthier world. It moves us beyond seeing the social determinants of health as one part of public health, to embracing social and economic foundations as integral to any public health thinking, removing any demarcation between social determinants and behavioral or endogenous factors, and making it clear that there can be no health for one—regardless of our individual efforts at health producing behavior—without our collective engagement in the forces that create the world around us.
But, to paraphrase the oft-quoted aphorism, vision, without execution, remains hallucination. How then do we go about achieving this radical vision? How does public health move from a field that, until relatively recently was seen by the public, and in large part saw itself, as being concerned with core functions of disease control and prevention, to one that is seen, and sees itself, as engaged in the business of creating social structures that generate healthy populations? This is where, I would argue, we need to marry our radical vision with an incremental approach that recognizes the complexity of the task at hand. I recognize that this is an inopportune time to suggest incrementalism of any kind. Revolutionary times call for bold and dramatic actions, and incremental change must surely be for those without the boldness of vision to see past the moment to the opportunity it represents. But I argue that it is precisely because we should be bold and serious in our intent to achieve our radical vision that we should embrace an approach to incremental change to get there.
If we understand that it is a complex set of powerful forces that creates health, we need to also understand that these forces each have structures that have created them the way they are at the moment, with sets of interests that have much to gain by maintaining the status quo. If we are, as public health, to aspire to put health at the heart of policy actions around areas as disparate as transportation and education, we will need to learn how to work with those who have been in that arena for decades, who have been socialized to think about education and transportation in a particular way, and for whom health has never been more than a secondary concern consigned to someone else’s area of focus. Engaging stakeholders in these sectors requires patience, persuasion, empathy, and persistence. It requires us to adopt a posture of learning. It requires, perhaps above all, our willingness to accept small changes that together accrete to create bigger change, one step at a time. It requires us to bear witness to forces long-ignored in the pursuit of health. And it requires our unflinching commitment to achieving our radical vision, recognizing that doing so takes years and decades.
It seems to me that a radical incrementalism in public health, the articulation of a radical vision combined with an incremental approach, stands to best capitalize on the promise in the moment. And that doing so takes courage and boldness on two fronts. It takes courage to say that health should be a motivational force behind how we build our world and as such should be integral to the breadth of sectors that create that world. It also takes boldness to say that, in order to get there, we will need to create the partnerships that take time, to re-think how we teach and learn public health, to make changes one at a time that eventually will see our vision flourish, and that the hard work of execution lies with the small incremental gains that accrue every day in the hard work of transforming complex systems that are not likely to yield quickly. A radical incrementalism in public health stands, to my mind, as a viable, tractable agenda, consistent with our aspirations, and attuned to the realities within which we operate.
 Galea S. The complicity of the population heath scientist. Milbank Q. 2018;96(2):227-230.  DeSalvo KB, O’Carroll PW, Koo D, Auerbach JM, Monroe JA. Public health 3.0: Time for an upgrade. Am J Public Health. 2016 Apr;106(4):621-2.  Galea S, Annas GJ. Aspirations and strategies for public health. JAMA. 2016;315(7):655-656.  Institute of Medicine. The Future of Public Health. National Academy Press; Washington, DC: 1988  Centers for Disease Control and Prevention. Core functions of public health and how they relate to the 10 essential services. https://www.cdc.gov/nceh/ehs/ephli/core_ess.htm. Accessed October 26, 2020.
Sandro Galea, a physician, epidemiologist, and author, 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. He has published extensively in the peer-reviewed literature, and is a regular contributor to a range of public media, about the social causes of health, mental health, and the consequences of trauma. He has been listed as one of the most widely cited scholars in the social sciences. He is chair of the board of the Association of Schools and Programs of Public Health and past president of the Society for Epidemiologic Research and of the Interdisciplinary Association for Population Health Science. He is an elected member of the National Academy of Medicine. Galea has received several lifetime achievement awards. Galea holds a medical degree from the University of Toronto, graduate degrees from Harvard University and Columbia University, and an honorary doctorate from the University of Glasgow.
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