Monograph Menu Report Home Director's Foreword Table of Contents Tables and Figures Acknowledgements Abstract Prologue Introduction Navigating Health Futures Valuing Conditions Crafting Conditions Perceiving Dynamic Conditions Reorienting Public Health Work Transforming Conditions Reflecting on Public. Health. Work. Glossary References About the Author Download Full Report (PDF-8.9Mb)

Transforming Conditions

Directing Change

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If we want to work toward a future that is not dominated by the inequity of allowing some of us to endure excessive vunlerability, along with the constant and growing pressure of vulnerable people becoming diagnosed with an array of mutually reinforcing diseases, then we must endeavor to expand people’s freedoms to make healthier choices. This task requires us to embrace the power of public work in its largest democratic sense and then direct it toward creating a balanced system of health protection. Thinking in the most practical terms, we must ask, “who is going to do that work?”

Public work calls on each of us—as we observed in Hawaii, East Brooklyn, and North Karelia—to labor side-by-side with people unlike ourselves in an effort to establish healthful conditions for all. Strictly speaking, the more appropriate question is not, “Who will do this work?” but rather “Are we preparing our children for it?” If not, our failure to do so must stand as one of the greatest threats to the health of populations and the health of our democracy. If not, we are squandering the creative energy of each generation, and virtually guaranteeing a future in which health and other human service professionals must set up elaborate operations downstream to save the few they can amidst the many who will inevitably (and unnecessarily) be lost (Landau, 1997; Landau-Stanton, 1990; Seaburn, Landau-Stanton, Horowitz, 1995). As Harry Boyte and his colleagues at the Center for Democracy and Citizenship have argued, we can no longer afford to raise young people under the adage that “youth are the leaders of tomorrow.” Rather, young people at every age must come to see and experience themselves as important, powerful players right now (Boyte and Farr, 1997; Hildreth, 1998; Hildreth, 2000; Public Achievement, 2004).

Equal to the priority of introducing youth to the realm of nonpartisan politics is the task of bringing professionals, and the institutions that they lead, out into the world of citizenship. After all, it is professionals who currently command the resources and possess the mandate for organizing health protection ventures. But many professionals worry that a deeper engagement in political action—even in the broadest nonpartisan sense—will somehow undermine their expertise or cloud their objectivity (Fortun and Bernstein, 1998). This view implies that becoming and behaving as a professional must also mean standing outside the public. As Len Syme, one of the pioneers of social epidemiology, candidly disclosed,

All of us know that we need to work with the community {as an empowered partner}. We may know it, but we also know how difficult it is to do. Especially if you have been trained, as I have been, to be an arrogant, elitist, prima donna expert. We are experts, after all, and all we are trying to do is help people by sharing our expertise. And therein lies the not-so-boring problem. (Syme, 2004)

What changes when experts act more like citizens? In a way, we get the best of both worlds: the specific knowledge and insights from their specialized training, as well as the combination of pragmatism and creativity that come from an approach grounded in a respect for others. Table 2 contrasts the focus, discourse, stance, goals, philosophies, and skills that are most salient under the outside expert vs. citizen actor framings.
 

Table 2: Two Contrasting Orientations: Outside Expert and Citizen Actor49
	Outside Expert	Citizen Actor
Concerns	• Efficiency of means • Emphasis on “How to...”	• Consistency of values between means and ends • Emphasis on “Why to...” and “How to...”
Discourse	• Technical	• Political (nonpartisan)
Stance	• Seeing from one or more disciplines	• Seeing from the world or a particular place
Goal	• Fix problems	• Create values • Develop capacities • Exercise freedoms
Philosophy	• Positivism	• Pragmatism
Key Actor (s)	• Authorities and people with credentials • Partners	• Citizens (each with his or her own expertise)
Skills	• Authorities and people with credentials • Partners	• Visioning • Integration and disaggregation • Analysis and synthesis • Cycles of organizing, acting, and reflecting
Commitments	• Experimenting • Proving	• Promising • Forgiving
Dynamics

Almost by definition, many professionals are vulnerable to becoming separated from the public they purport to serve because the institutions in which they work tend to emphasize the first column over the second. Certainly, public health organizations are not unique in this regard. But they can become pioneers of a new approach (Boyte and Kari, 1996b). Following this path may be fraught with difficulty, but it promises to nurture cadres of citizen-professionals whose dual role is celebrated rather than undercut.

One example of the sort of change that is possible on an institutional level is evident in the CDC Futures Initiative (Centers for Disease Control and Prevention, 2004d). Since 2003 CDC’s workforce has been engaged in an intensive strategic direction-setting effort that touches on many of the questions raised above about the relationship between expertise and public health work. The Futures Initiative has many elements that foster a stronger public sensibility: an “outside-in” view, inviting honest input from both traditional and nontraditional partners; a commitment to public dialogue about CDC’s organization, strengths, and shortcomings; more transparent processes for decision-making and governance than in the past; a shift to viewing members of the general public as the primary customers for the agency’s services; and a growing focus on achieving real health protection impact across every lifestage, in a variety of places, and under many preparedness scenarios (Centers for Disease Control and Prevention, 2005a).

If enacted, these new directions and the synergy among them bode well for the future. Yet these changes in perspective also highlight some specific and potentially uncomfortable challenges. Beyond incorporating new and different voices into CDC’s work, a harder task will be creating an enduring culture of public-minded, citizen-professionals among the agency’s scientists, researchers, and administrators.

CDC staff have plenty of company in other scientific institutions in the cherished belief that scientific pursuits are somehow removed (and perhaps even excused) from engagement in the political arena. This attitude separates public health professionals from the citizens they serve and from their own potential contributions. To achieve meaningful changes in the conditions for health, the public health workforce will have to address this issue head-on.

A further challenge is the double-edged sword of seeing members of the public as customers of prevention services. The decision to position members of the general public in this way is meant as a tribute: the customer as king, driving what we do, how we communicate it, how we gauge the success of our efforts. Yet buried within that relationship is a hierarchical power dynamic that may not be intentional, but is still potentially destructive to the larger endeavors of building public strength and assuring equitable conditions for health.

First, despite eliciting input from various members of the public (through mechanisms like commentary on draft documents, focus groups, representation on coalitions and evaluation teams, and survey research), CDC’s communication with its customers overwhelmingly moves in one direction: from the agency’s experts outward. Moreover, the nature of this arrangement seems to have been solidified, at least linguistically, with the creation of a new Center for Health Marketing (Centers for Disease Control and Prevention, 2004b).

Second, the CDC’s historic tendency to address separately the array of risks and diseases for which it bears responsibility is cemented by the practice of grouping citizens into market segments by their common problems. This approach, if pursued exclusively, has the untoward consequence of labeling people as problems rather than acknowledging their status as fellow citizens capable of working to achieve a healthier future.

As the CDC and other health institutions wrestle with these dilemmas they may find inspiration in the perspective Harry Boyte articulated in his essay on “Professions as Public Crafts.”

The National Commission on Civic Renewal defined democracy as “neither a consumer good nor a spectator sport, but rather the work of free citizens engaged in shared civic enterprises.” To spread such a dynamic view of democracy on any significant scale in our world of large systems and extensive, information-based occupations will require new models of professional training and practice that adapt themes of craft and “publicness” for today (Boyte, 2000:1).
 

49. Adapted and synthesized from (Arendt, 1958; Boyte, 2004a; Eoyang, 2001)

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Page last reviewed: January 30, 2008
Page last modified: January 30, 2008

Content source: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion