The Simplicity of Politics and the Complexity of Public Health
The heart of public health may reside in our public systems, but the soul of health forever resides in people
The human soul is a precious, complex creature. Consider the internal drive, judgment, assessment, and executive function, all of which operate within a lifetime of accrued experience. That can make for some unexpected outcomes.
But whatever the outcome, human complexity scales up dramatically as you add more and more people to the mix. In public health, it is this complexity that drives a multi-pronged problem which, although exacerbated by recent events, actually began many years ago. If you’re unfamiliar with this problem, you’ll be properly introduced once you’re acquainted with Nic’s story. Nic is a redacted name, but the story is very real.
Nic was born and raised in Southern California, where he currently resides with his wife and youngest son. His two older sons are adults, out in the world and serving new communities, guided under the values and principles of the home in which they were raised. Nic and his wife are upstanding individuals who raised their sons in love, warmth, and support. The home they figuratively built was grounded upon the values of their faith, where each boy grew to manhood esteeming honor, work ethic, kindness, and growth.
This humble family, in their seemingly ordinary life, takes a turn into the extraordinary when you consider how Nic’s home of today is an inverse reflection of his own childhood, which was devoid of the very love Nic now gives his own children. Nic’s father was an alcoholic, and rarely present at home or in company. His mother was equally disconnected, content with the meager living that life afforded. Abuse was normative. Meals often consisted of materials purchased at a gas station. One bright spot of hope in this situation was an adult relative who, as Nic describes him, was the father Nic needed. He set boundaries, punished poor behavior, maintained standards of conduct, and connected Nic to an alternative community that afforded new opportunities for meaningful relationships. In this setting, Nic saw the potential for a better life, despite his destitution. It was here that Nic met his future wife, a woman raised in the very sort of home that Nic would one day create.
Poverty. Addiction. Violence. Food insecurity. All of these exist within the realm of public health’s purview, each a social ill that shortens life and deteriorates standards of living. Yet somehow, here is a man who experienced it all, yet was moored by relationships, an alternative community, hope, and progression through personal discipline. Nic created beauty out of pain.
Now. Here is the problem.
How do you solve Nic’s problem with a yes-or-no vote, cast in a chamber housed many miles away, by hundreds of strangers who have never met him?
This is the crux of public health’s present dilemma: An empirically grounded, yet altogether incoherent argument that you can resolve human complexity with a binary vote.
It’s Always Political
“I just don’t like it when it gets political” is a refrain on public health, that public health officials have heard more than once over the years. Setting aside any introspection of that statement, there is a simple and appropriate response as to why public health is always political.
The three core functions of public health include:
Assessment of a population’s health
Policy development to improve the population’s health
Assurance of competent, consistent health services to the public
It is that 2nd core function which affirms the political necessity of public health’s nature. Policy is a function of the legislature. The legislature is a branch of the federal government. The business of the government is to operate within its prescribed powers to manage public affairs, and maintain public good and stability.
Stated more succinctly, the business of government is politics. So before going any further in the problem of public health, we should first justify the necessity and relevance of policy development for the health of human beings.
Individual agency is a gift which operates in the milieu of environment, circumstance, and opportunity. People choose, and choices are affected by our environment. This is an inarguable position. If I surround an individual with apples, intermixed with one or two bags of chips, that individual is overwhelmingly more likely to eat more apples than a person existing in the opposite scenario; surrounded by chips with a few apples here and there. Nudge theory, choice architecture, and human psychology can offer relevant predictions for how people will behave given certain circumstances.
But all predictions aside, how do you explain someone like Nic? Everything we know about public health predicts that Nic should have followed in his father’s footsteps. He is a statistical outlier, to be clear, so if we corrected the poverty, addiction, crime, and food insecurity, would we get more outcomes like his? Simple logic suggests that yes, we would. So there’s the rub. How do you correct these systemic social ills? What is the solution?
The Price of Engineering Humanity
It’s difficult to discern a precise number, but there is good evidence to suggest that appropriations bills — the allocation of federal funds — make up a sizable portion of congressional votes. Investing in public infrastructure, social welfare programs, defense, education, research and so forth all arguably provide for the maintenance and improvement of civilization.
Recently, the 119th Congress passed H.R.1, more informally referred to as “The One Big Beautiful Bill Act”. This is not the place to dissect the bill, but simply stated, it grants Congress permission to spend money in some areas, and cut spending in others. The cuts represent reversals on the goals of previous administrations, and the new expenditures bolster controversial topics. It has ever been thus. Congresses come and go, and spend money in ways which follow the cultural stream.
But at the end of the day, money is spent. Lots of it. The federal budget for fiscal year 2024 was 6.75 trillion… with a ‘t’… dollars. The scale of that amount defies most human imaginations. For instance, if you were written a check for a million dollars, what would you buy? What could you buy?
Now imagine you have $10 million to spend. What then?
Now you have $100 million. If you spent $100 million every day, it would take you a little more than 27 years to spend $1 trillion dollars.
If we presume that human health outcomes merely require paying the proper fiscal amount, however that manifests, what does that figure look like? How much exactly do we need to pay before we start seeing the desired outcomes?
At the very least, we know the answer is not $36.6 trillion, the current debt of the United States as of today.
Before anyone argues, “We’ve not been spending money on the right measures,” it’s worth asking if you know where the United States spends, and historically has spent most of its budget. The top four expenses of the federal government are
Social security - 21%
Medicare - 14%
Interest (on our growing national debt) - 14%
Health - 13%
We are spending 48% of our budget on items that directly related to public health. So one more time, the question.
How much money do we need to spend before we start to see improvement in this arena?
The Policy of Engineering Humanity
The issue is not merely the money, as Congress is also involved in regulation of industry, passage of new laws, and development of departmental policy which trickles down and influences citizenry.
But back to Nic. What law, or series of laws, would Congress need to pass that would have prevented the circumstances of his childhood? The question is intentionally designed to think about the circumstance of Nic’s life. Whereas most public health officials would see his problem as an issue of poverty, that is not what initiated his father’s alcoholism, nor his mother’s laissez-faire approach to life and family.
Had someone stepped in, showed up to Nic’s childhood door with a suitcase full of $100,000 in cash as a gift, or declared alcoholism to be illegal… it does not take much imagination to reasons that these offerings would have been useless gestures at best, and gasoline on a fire at worst.
But we need laws, and policies, and improvements to social systems that increase the likelihood of bad things happening. It’s horrible to consider, but if murder were not illegal, there would be more murders. If there were no speed limits, there would be more motor vehicle accidents. If drugs and alcohol are more rampant, addiction will increase.
But the alternative perspective to this is a chilling prospect.
There are people who choose not to murder, simply because it would get them in trouble. I’d much rather live with people who don’t need a consequence to never consider murder.
There are people who choose not speed, because they don’t want to lose money or driving privileges. I’d much rather live among people who impose restrictions upon themselves, for fear of how it would potentially harm others.
The perspective that you personally adopt — the internal locus of drive, or the external locus of force — probably rests with whether or not you believe you can engineer people to always make the right choice.
What a prospect. Here, then, are a few a concluding points.
The heart of public health may reside in our public systems, but the soul of health forever resides in people.
Nic’s story reminds us that lives are not shaped solely by funding formulas or statutes. They are shaped in kitchens, in churches, in gyms and classrooms and recovery centers, driven constantly by the choice of human beings to invest in themselves and other human beings. And yet, we cannot abandon systems because they are a natural part of the cultures we create, a method to scale our lives in a way that helps the exceptional become more common.
Public health, then, should not be viewed as the science of “fixing” people. Exaggerated faith in a binary vote’s ability to rectify all that is unfair about life is a doomed prospect. Rather, it is the art of building environments where bad behavior can become good, and good behavior can become better. It requires the promotion of qualities and beliefs that have no fixed cost, including purpose, character, and sacrifice. It requires a more involved citizenry, perhaps even more so than those who are elected to write and pass laws.
That is the tension. That is the cost. That is the task, complex as it may seem.
But considering the value of the human soul, it is worth it.