Good afternoon. On behalf of those graduating today, I would like to thank you all for celebrating with us as we bring our studies to an end.
When I told my father that I would be speaking before you today, he suggested that I start with some cannibal jokes, awkwardly inserting various public health officials into old jokes that invariably left the poor cannibals with food poisoning or some other dire public health concern. With the exception of my father, I’m certain that everyone will be relieved that I have chosen instead to go in a different direction. I’d like to discuss what it means to work in public health today.
Health is not an end in itself. But health is a necessary precursor to all sorts of valuable ends – like quality of life, fulfilling relationships, and, particularly, the freedom to actively participate in society. It means that those of us who work in public health have a stake in how society functions. Our studies over the course of this program have highlighted how individuals, populations, societies, and even nations encounter the intersection of health with governance, commerce, justice, and equity. The study of public health is unusual from many other disciplines in that it incorporates both practical application and conceptual constructs. We may notice it as a difference between the applied and the theoretical…or as the difference between hard homework and frustrating homework. I like to call it the difference between science and politics. Public health workers do science in the political – and public – sphere.
Notice that today we see political reactions to practical work. Those of us that go on to work for federal, state, or local governments may be seen as prime examples of how the public sector is destroying this country and driving it into bankruptcy. Those of us that go on to work for international organizations may be seen as self-righteous do-gooders extending American hegemony across the globe. Those of us that go on to work for insurance companies may be seen as evil corporate hucksters making a buck off the fears of an aging, and ailing, nation. While these characterizations mostly misrepresent the work of these institutions…well, except for that bit about insurance companies…these political reactions to practical work leave us in a tricky spot. Are we scientists or politicians? Theorists or pragmatists?
I think that we tend to retreat into the science at the expense of the political. We opt for the normative over the positive, the responsive over the proactive. The practical matter of finding and applying for jobs forces us to highlight our practical skills and experience while leaving our theory where it safely belongs, in a paper turned in at the end of a semester. Is that such a bad thing? No. We’re here to do a job, to crunch the numbers, to survey the population, to direct the program, to write the grant, to set the priorities, to educate the public. These are public health activities, necessarily performed in the public sphere. But all public acts are political acts. This means that public health is a political act.
So, again, are we scientists or politicians, theorists or pragmatists? We’re both. And here is where, I think, it gets interesting. If we’re scientists and politicians, why do we hear, paradoxically, “don’t mix politics and science”? We hear it because it’s sound advice. Politics shouldn’t determine the course of scientific investigation unless we want all of our researchers working on ways to get elected to public office. Nor should science determine governance unless we want our iphones commanding us to jog and to cut out the salt, while scientists unilaterally decide to defund social services to pay for a manned mission to Mars.
What’s the point in being both a scientist and a politician when you have to keep these fields so carefully separated? Well, that’s the beauty of graduate studies in Public Health. Maddening, yes. But also illuminating. Most of us have, at one time or another, been sitting in an epidemiology course wishing we could be studying a Marxian analysis of the WHO’s version of the determinants of public health (who thinks of this stuff?). But most of us, wrestling with that paper on why income disparities in low-income countries so often seem to be tied to western neoliberal economic ideology, have also, at one time or another, wished that they had some good, solid data to work on that would result in a single, nice, statistically significant percentage.
This has been good for us. We need to make those connections between practice and policy. And the practice and policies of Public health, I think, meet at and play an important role in the social contract. The social contract is maybe not the ideal topic for an occasion like this but I promised Jessica that I wouldn’t be quoting the lyrics for that Greenday song they play at graduations, so we’ll have to make do. Whether we view the social contract simply in terms of escape from the Hobbesian nightmare where we were just struggling for life; or in terms of John Rawls’ concept of justice embedded in just institutions where the social determinants of health are fairly distributed; or Amartya Sen’s more universalist ‘capabilities’ approach that appeals to the comprehensive, and positive, social outcomes embedded in his version of social choice theory where the concept of “freedom from” is only a precursor to the concept of “freedom to”,…however we view it, we must realize that the social contract is being rewritten daily and that public health professionals play a part. If we are concerned with justice and ‘capabilities’ and equity, and we realize the role that public health can play in empowering a population to realize and achieve these things, we have no choice but to wrestle with the notion of the part that public health plays in the social contract.
I have a few ideas about this. If our version of the social contract does, indeed, place a high value on justice and equity, and if health is a necessary precursor to active engagement in ensuring and realizing these concepts, public health professionals have a responsibility to the public beyond what health-related activities alone may suggest. This is where, without mixing the two, we find ourselves called to be scientists and politicians at the same time. Our political engagement is informed – though not determined – by what we see in practice. We work not simply to provide ‘freedom from’ disease, to respond to disease; and not simply to promote health as the absence of disease, not simply to monitor populations, or to evaluate programs, but to do all of these things in order to actively equip a population with the ‘freedom to’ (as opposed to the “freedom from”) …the ‘freedom to’ seek justice and equity, and to realize and achieve individual and collective ‘capabilities’.
Public health is not the only necessary precursor for guaranteeing a social contract that values justice and equality, but it is the one in which we have chosen to study and work. As such, we must remember to keep our politics and our science separate, but we also remember when to be a scientist and when to be a politician. We must remember who benefits from science and who benefits from policy. And we must remember that the work we do doesn’t end when we’ve reached a target goal or when our population is free of a particular health issue. It ends when a population is empowered to achieve to the fullest of their ‘capabilities’ … or when the funding runs out, whichever comes first.