Syndemic Prevention Network: Monograph -- Seeing Conditions as Freedoms

Even though public health work is ultimately about assuring the conditions in which all people can be healthy, the practical tasks of identifying, creating, and safeguarding those conditions in a dynamic and democratic world have only begun to be defined and justified (Gostin, Boufford, Martinez, 2004). By contrast, the IOM’s three core public health functions—assessment, policy development, and assurance—have been more fully translated into practical forms like essential services (Public Health Functions Steering Committee, 1999), performance standards (Centers for Disease Control and Prevention, 2004e; Corso, Wiesner, Halverson, et.al., 2000), and training competencies (Public Health Functions Steering Committee, 1997; Tilson and Gebbie, 2004). In the 19 years since the initial call to reorient public health work around the challenge of assuring conditions, there is still no clear, operational statement about precisely what those conditions are. This is equivalent to not having identified our most basic values, not having answered for ourselves the essential navigational questions that Thompson posed to those 18 school children. Where do we want health-related conditions to go? How shall we prepare to get there? Who among us will do that work? What forms of resistance must be overcome?

The Ke Ala Hoku project, and thousands of other visioning efforts like it, have attempted to address similar questions, with varying degrees of seriousness and completeness. For instance, the first international conference on health promotion in Ottawa, Canada articulated a set of “prerequisites for health” in the widely-cited Ottawa Charter (World Health Organization, 1986). These included: peace, shelter, education, food, income, a stable eco-system, sustainable resources, and social justice and equity. But, as profound as that list of prerequisites is, its articulation 20 years ago has yet to significantly shape the main thrust of policy dialogues today, which continue to focus on how to manage each item on a long list of risks and diseases without necessarily joining those questions with ones about creating and assuring the related conditions for health (McKinlay and Marceau, 2000b; Milio, 1981). Even worse, the absence of a robust and complementary focus on policies for improving adverse conditions, out of which all diseases and risks emerge, is itself not widely acknowledged to be a problem.

In the United States, for instance, the Healthy People 2010 national objectives are not organized around a clear set of conditions to be assured, but rather into 20+ separate chapters, each focused on a different disease or risk behavior. A few additional chapters are devoted to conditional objectives (i.e., access to health services, educational and community-based programs, food safety, the environment, and public health infrastructure), but there is practically no explanation for how those particular conditions were selected nor the extent to which they cover the full spectrum of conditions that must be assured (United States Public Health Service, 2000).

What does it really mean to have—or not have—adequate conditions for health? Despite all that we have learned through public health research, there remains little agreement around this central question. Consequently, many thinkers and writers tend to become caught in tiresome, unproductive debates over a false dichotomy between individual and social responsibility for health.¹²

One way of fostering a better dialogue is to consider the degree of choice (or lack thereof) that people have over the conditions that affect their health. Levins and Lopez frame the matter this way:

In a similar vein, the World Health Organization (WHO) summarized the views of many observers by defining living conditions as “the everyday environment of people, where they live, play and work. These living conditions are a product of social and economic circumstances and the physical environment—all of which can impact upon health—and are largely outside of the immediate control of the individual” (World Health Organization, 1998:16). Note that these conditions were not seen as uncontrollable, but rather outside the immediate control of individuals. This framing leaves open the possibility that groups of people, organized in ways that harness the synergy of their relationships and resources, could develop sufficient power to govern the course of change (Chambers and Cowan, 2003; Lasker, Weiss, Miller, 2001).

We are still called upon to give aid to the beggar who finds himself in misery and agony on life’s highway. But one day, we must ask the question of whether an edifice which produces beggars must not be restructured and refurbished.

-- Martin Luther King, Jr

Based on this understanding, adverse living conditions might be defined as circumstances that inhibit people’s freedom to live and to develop their full potential.

They may include, at a minimum, any deviation from the conditions necessary for life and human dignity, including phenomena like hunger, homelessness, joblessness, illiteracy, war, environmental decay, and various forms of injustice or oppression, including racism. These, in turn, are among the conditions that sustain entrenched vulnerability, both within nations and internationally. They must therefore become objects of concern not just by those most directly affected, but of broad-based public concern as well, including that of health professionals who are trained to do public health work.¹³

If choice and control enter the mix in both individual and social ways, then it may be useful to follow the lead of Nobel laureate Amartya Sen and think of the conditions for health as an array of freedoms (Sen, 1999). Physical security, for example, entails freedom from hazardous physical exposures like excessive heat, cold, radiation, or toxic chemicals—freedoms that are not at all randomly distributed among sub-groups in society (Clifton, 2004; Jackson, Locke, Pirkle, et.al., 2002; Klinenberg, 2002). Likewise, the condition of peace entails freedom from violence in all forms (Krug, 2002). Having a minimal standard of living demands freedom from deprivation in a material sense as well as from undue dependency in a social context (Moynihan, 1973). Social engagement depends on countering the disconnection that comes from inequality, injustice, and various forms of social mariginalization (Berkman, Glass, Brissette, et.al., 2000).¹⁴ The maintenance of stable organic processes and mental/emotional balance all rely on maximizing people’s freedom from the array of biological, psychological, emotional, and spiritual impairments that can disrupt these essential conditions for healthy living.

Another important feature of these conditions/freedoms is that they operate together, through synergy, rather than separately, through partial accumulation. As Peter Corning, the biologist best known for revealing the causal role of synergy in evolution (Corning, 1998, 2003), correctly points out,

If our health depends on the continuity and combination of such a vast array of conditions/freedoms, then that opens the whole health protection enterprise in a very particular way to the influence of each person’s work. It also raises immediate questions about our power as citizens, how that power is used, and whose efforts ultimately shape the prospects for a healthy life (Walt, 1994).

History shows that people acting to protect what they value have a profound ability to direct the course change, with corresponding effects (both positive and negative) on their own health and that of others near and far. Acting in this way, organized citizens have navigated significant social movements such as those to abolish slavery, dismantle legal segregation, outlaw child labor, and clean up the environment, to name just a few with the most obvious health benefits. Such endeavors often must be sustained over decades or centuries, but when they take hold, they can change the course of history. For those involved and for the generations that follow, they literally move the world in a safer, healthier direction.

That said, it is also possible to move simultaneously in very dangerous directions, away from relatively healthful conditions. In the 20^th century, for example, the proliferation of destructive weapons (Cirincione, Wolfsthal, Rajkumar, 2002; Potter, 1982; Rhodes, 1986), large-scale environmental degradation (McNeill, 2000; Meadows, Randers, Meadows, 2004), profit-driven “disease promotion” (Freudenberg, 2005); and repeated attempts at genocide and ethnic cleansing (Hinton, 2002; Weitz, 2003) stand out as some of our most troubling trajectories. That both healthful and unhealthful movements can proceed simultaneously, and interact with one another, is a testament to the sheer enormity—and perpetual need for—the “concerned, humane, directed science” that guides public health work.

12. Common sense suggests that there is nothing mutually exclusive about the two, and indeed many people admit that both individual and social forces affect the public’s health (Mann, 1999). Still, the professional literature remains filled with extreme arguments framed around an assumed dichotomy. For more details see: (Gori, 2001; Koopman and Lynch, 1999; Lukes, 1973; Raphael, 2002)

13. Because of their role as providers of highly specialized services, health professionals often do not recognize and respond to vulnerability and social disparity for its own sake, in the same way that citizens without professional health training often do. For more on this aspect of professionalism see: (Farmer, 2003; Illich, 1982; Light, 1997; Starr, 1982)

14. One stark example is the recent trend toward large-scale incarceration as way of dealing with public problems (The Sentencing Project., 2004)

Valuing Conditions

Seeing Conditions as Freedoms