Of Public Health, Policy, Politics, and Trees

Abstract

If the Earth were flat and human logic followed a linear scale, one would expect the public health machinery to be promptly alerted to new threats; build evidence of these threats’ nature, magnitude, and causes; suggest remedies; and help frame effective public health responses, which, in turn, would be open to a democratic political debate responsive to the evidence set forth. Political fine tuning, along with leadership commitment, resource allocation, and when needed, appropriate legislation, would follow promptly, with public health practitioners already having moved on to embark on new tasks. Instead, because the Earth is enjoyably round, and human logic a personally defined concept, reality tells us differently. Until the last century, politics had been primarily the exercise of power in government decision-making, but this is no longer the case. Governance decisions are increasingly affected by nonstate actors—the private, commercial sector, in particular, because of ever-expanding economic globalization. In the past, domestic politics were chiefly concerned with the needs and claims of citizens and the distribution and use (or misuse) of power within national boundaries. They no longer are, as international agreements and regional geopolitical aggregates expand the boundaries within which domestic policies have to find their place. International politics, likewise, used to be concerned with matters of territorial integrity, bilateral trade, defense, and security, but new themes have found their rightful place in international political fora—public health and climate change among them. The theoretical linear relationship between public health, policy, and politics—if it ever existed in practice—is affected by complex interactions at every stage of the evidence-to-decision chain, turning the concept of the decision tree from a palm tree, with decisions emerging from a barren axis, to a Christmas tree with on every level a number of ramifications creating as many opportunities for diversion of attention, energy, focus, and resources. In addition, through this nexus of complex and intertwined, multilayer ramifications, evidence can be considered, distorted, lost, or ignored. As public health practitioners, we are often dissatisfied with the little attention given to our claims. Are politicians not listening, not hearing, or not caring? Surely, in modern democracies, they do all of the above, even as it often appears they have great difficulty seeing the forest for the trees. Politicians are responsible for finding the optimal pathway to sound decisionmaking through the maze of ramifications that may distract and confuse them. When it comes to decisions regarding public health, some politicians ensure political gains first and foremost by falling back on ideological or so-called faith-based principles, regardless of the evidence presented. Others find their way, courageously taking political risks to advance public health causes. Still others make every effort to examine all the facts in making decisions and yet receive from public health practitioners a cacophony of opinions—some more or less informed by reality—in a language incomprehensible to them. Through research, practice, advocacy, and more-effective communication, we public health practitioners have to better generate and interpret emerging evidence, package it in a way that can effectively inform policy and political choices, and remain aware that politics, policy, and public health are human sciences; the evidence in which they are rooted is but one branch of the towering tree.