I joined the Kansas Health Institute as Senior Fellow at the beginning of 2004, almost 18 years ago! Before I came to KHI, I had already spent about 15 years working in public health in multiple countries and positions. Regardless of the type and place of work, I always loved my jobs and found them fulfilling and meaningful. I found the goal of improving the health status of entire communities meaningful, as it allowed me to go beyond helping one patient at a time where I was often sending them back into a system that made them sick to begin with. Despite that satisfaction, I have decided the time has come for me to pass the baton to someone else and retire.
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At the risk of stating the obvious, I must say that public health in 2021 is quite different from public health in the 20th century. I’ve witnessed a shift in the focus on programs addressing single diseases – e.g., cardiovascular disease, stroke, influenza, etc. – to a more comprehensive target that includes whatever is killing people or making them sick. This soon steered epidemiologists and other public health practitioners toward issues that, in previous decades, would have been beyond the scope of public health, such as gun violence and unintentional injuries.
The terrorist attacks of 2001, including the mailing of anthrax-tainted envelopes, was a turning point for this nation and for public health. Those events added another dimension to the public health job description: emergency response. These changes reshaped the lives of many public health workers, including myself. The idea of needing a security clearance to do my job (which happened to me and many others after 2001) had never occurred to me before!
Once we moved away from the disease-based model, the horizons of public health expanded dramatically. Before long, our digging deeper into the question of what makes people sick led us to rediscover that a lot of that depends on factors outside the traditional public health field. Poverty, education, income, the built environment, and other social factors have a profound effect on people’s opportunity to live a healthy life. This realization within the system resulted in a focus on the social determinants of health. This, in my viewpoint, was nothing new, as the historical roots of public health have always been about removing external factors that interfere with people’s health, whether that is poor water and sanitation or inadequate education and income.
Within this movement toward addressing social determinants of health (i.e., factors outside the direct control of the public health sector), we recognized the need for allies in this work. Public health acknowledged the need to create broad partnerships with multiple stakeholders, some more traditional (e.g., health care sector and education) and others whose links to our work were sometimes not immediately evident (e.g., transportation and housing). The ability of public health leaders to forge those relationships in their communities has become a key factor in the advancement of our work in the past few years, and best practices for doing that are being promoted more and more.
The last few years have seen yet another shift – perhaps even greater broadening – in the public health mission. The evidence became overwhelming that social and racial issues are powerful predictors of health at the community and individual levels. The effects of decades of discrimination still reverberate today and affect people’s opportunities to live healthy lives. For example, public health officials learned about redlining (essentially sets of local, state and federal housing policies that mandated racial segregation by refusing to insure mortgages in and near African American neighborhoods) and how it affected the ability of minority families (in particular, African Americans) to build any significant family wealth that could be passed from generation to generation. The focus on the role of racism in affecting public health has gone as far as inducing many prominent public health organizations and agencies to declare racism a public health emergency. Researchers and practitioners are concluding in growing number that no meaningful advancement in reducing the health disparities in our communities will take place unless racial and socio-economic disparities are addressed.
I would be remiss if I did not mention the ongoing coronavirus pandemic as a major force of change for public health. Burnout and conflicts are causing many public health officials to leave their position, losing a wealth of collective experience and wisdom that will be difficult to rebuild. Across the state of Kansas, local health departments lost nearly 60 leaders, either a health administrator or health officer, in the past two years! But perhaps the largest changes are those created by the plethora of federal and state legislation and local laws that imposed very specific restrictions on the authority of public health officials. For over a century, the police power of public health (defined as the ability to restrict individual and collective freedom in order to protect the health of the community) had been left largely untouched. Public health officers had used that authority in very rare circumstances, usually without much notice from the rest of the community. The deep politicization of the pandemic response quickly led some people to take strong-held, rigid positions against the use of those restrictions. In some states, including Kansas, public health officers have been stripped of large portions of their authority to limit individual and collective movements or to adopt ordinances that they deem are necessary for the protection of the public’s health (such as limiting public gatherings or requiring the use of masks). This change occurred relatively quickly, with bills introducing major changes approved in a matter of days.
As public health has gone through many changes over the past decades, some have been quite substantial, as described above. All along, the public health workforce has exhibited a remarkable ability to pivot and adapt to changing circumstances. However, the pandemic response represented a turning point for many of us. When public health officials were originally given their police power, that was done on the explicit or implicit assumption that our collective health was important to the point of justifying some occasional limitations to our individual freedoms. That social pact no longer exists. Our society is currently divided over how collective and individual interests should co-exist. The absence of a social pact about the role of public health in our society is not something that public health officials can or should address alone. It is a fundamental agreement that we need to reach as communities and as a country. I trust that the public health workforce emerging from the pandemic experience will have the energy and ability to participate in that process. I will be watching, and cheering, from the sideline!
Hear more reflections from Gianfranco in the video below.